Virtual Consultation - Online Med History Form - Cosmetic Surgery Center of Phuket

First Name*
Last Name (Family Name)*
Date of Birth (Please provide CORRECT YEAR of birth)*

Day
Month
Year
Gender*
- Male
- Female
Height ( Please Specify CM or Feet & Inches)*
Weight ( Please Specify Pounds or Kilos )*
Where Do You Live?*
Street Address City ZIP / Postal Code Country
Phone*
Email*
Emergency Contact Name and Phone Number (family,caregiver or close friend)*
What Treatment Are You Interested In?*
Please Describe Your Expectation of outcome*
FOR WOMEN ONLY (CHECK ALL THAT APPLY)
- I take birth control pills/hormone replacement/wear a patch.
- I am pregnant now
- I am planing more pregnancies
- I am still breastfeeding/ My breasts still have milk at this time
FOR WOMEN WITH CHILDREN ONLY

Day
Month
Year

When Did You Deliver Your Last Baby?
Have you had any surgery or been hospitalized in the past 2 years?*
- Yes
- No
If Yes, please elaborate when and cause(s).

Online Medical History Submission Phuket Surgery