Surgical Evaluation Form


Please complete this confidential form for your FREE Surgical Assessment from one of

our board-certified Plastic & Reconstructive Surgeons.


Important Information:

  • Providing accurate information is crucial. Any false declarations may lead to the surgeon declining to proceed with surgery during your consultation upon arrival.
  • Conditions like diabetes can affect healing, increase scarring risks, and may require additional medical care or hospitalization at your expense.


**Please be aware that a final treatment plan can only be established after an in-person examination by the surgeon. The quotations provided are estimated costs based on the requested procedure and are subject to change upon further evaluation.



Full Name [as in passport]
Age
Gender
Date Of Birth
Nationality
Body Weight (In Kg's)
Height (In CM)
E-mail
Phone Number
Address
Emergency Contact Name
Relationship
Emergency Contact Phone Number
Emergency Contact Info. [address, e-mail]
Type of Procedure
Your Goals/Expectations
Any Concerns or Questions About the Procedure
Have you ever undergone any surgeries, including cosmetic procedures
If yes, please specify the type, date, and any complications
Do you have any chronic medical conditions? (e.g., diabetes, high blood pressure, asthma)
If yes, please specify
Do you have any allergies? (e.g., medications, anesthesia, latex, adhesives)
If yes, please specify
Are you currently taking any medications, vitamins, or supplements? If yes, please list them.
If yes, please specify
Do you have a history of blood disorders or clotting problems?
Have you experienced any complications with anesthesia in the past?
Do you have any history of heart disease or irregular heartbeat?
Do you have any respiratory issues? (e.g., asthma, sleep apnea)
Are you currently pregnant or breastfeeding?
Do you smoke?
If yes, how many cigarettes per day and for how long?
Do you consume alcohol?
If yes, how often and how much?
Do you use recreational drugs?
Does anyone in your family have a history of complications with anesthesia?
Does your family have a history of genetic conditions, heart disease, or diabetes?
Do you have a history of slow wound healing or infections?
Do you develop keloids or thick scars after an injury or surgery?
Have you had any recent infections or illnesses? (e.g., flu, fever)
Are you experiencing unexplained fatigue, weight loss, or other health issues?
Your Pre-Surgery Assessment Photos
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เว็บไซต์นี้มีการใช้งานคุกกี้ เพื่อเพิ่มประสิทธิภาพและประสบการณ์ที่ดีในการใช้งานเว็บไซต์ของท่าน ท่านสามารถอ่านรายละเอียดเพิ่มเติมได้ที่ นโยบายความเป็นส่วนตัว and นโยบายคุกกี้
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