Medical Questionnaire

Thank you for your inquiry with Hygeia Beauty. We will send you an e-mail with a brochure for your requested procedure(s). Please check your Inbox or Junk Mail for our reply .

You can now proceed to step 2 right away and complete our medical questionnaire below to find out if you are a likely candidate for your requested procedures.

 

  • Complete inquiry form
  • Complete medical questionnaire form
  • Complete booking form

    •  

    Your questionnaire and pictures will be reviewed by the relevant surgeon who will evaluate whether you are likely to be a candidate for your requested procedure(s). Please submit questionnaire and pictures at the same time!

     

    All fields must be completed before submitting the form.

     

    GENERAL INFORMATION

    Full Name (As In Passport):

    Age:

    Gender:

    Male Female

    Date of Birth:

    		 cosmetic surgery phuket

    Height (cm):

    Weight (kg):

    Nationality:

    Passport Number:

    E-mail:

    Phone:

    Address:

    PERSON TO CONTACT IN CASE OF EMERGENCIES

    Name

    Email

    		 Phone
    Address:

     

    SURGERY DETAILS

    Planned Date of Surgery:
    cosmetic surgery phuket

    Flying home on (Date):

    cosmetic surgery phuket

     

    What procedures do you require?

    What results do you expect? (Please be as specific as possible)

    Please specify the surgeon if any:

    Questions to surgeon:

     

    MEDICAL CONDITIONS (Please specify yes or no by clicking the box)

     

    Yes

    No

    		    

    Yes

    No

    Diabetes or blood sugar problems

    		 

    Thyroid problems



    Heart problems



    		 

    Lung problems



    Blood pressure problems



    		 

    Kidney or Liver problems



    Blood disorders



    		 

    Previous/current history of cancer



    HIV or AIDS



    		 

    Nervous Breakdowns/Depression



    Neurologic problems



    		 

    Anesthesia problems



    If you have answered YES to any of the above, please specify:

    Have you had or do you have any medical conditions not mentioned above?

    Yes No

    If yes, please specify:

    FOR WOMEN

    Do you take birth control pills, hormone replacement medication, or wear a hormone patch?

    Yes No

    Are you pregnant now?

    Yes No

    Are you planning any more pregnancies?

    Yes No

    When did you last deliver a baby?

    When did you last breastfeed?

    MEDICAL HISTORY

    Have you been hospitalized, had surgery or received medical care within the past 12 months?

    Yes No

    If yes, when?

    If yes, what was the reason for this?

    Do you have implants or any metal objects in your body?

    Yes No

    If yes, please specify:

    Do you have difficulty with healing or scarring?

    Yes No

    Do you have any allergies to food, drugs, etc?

    Yes No

    If yes, please specify:

    List all medications you currently take including dosage for each:

    List all vitamins or food/nutritional supplements you currently take:

    Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?

    Yes No

    If yes, when was your last dose?

    Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin?

    Yes No

    If yes, when was your last dose?

    Do you smoke?

    Yes No

    If yes, how much do you smoke?

    If yes, when did you last smoke?

    Do you drink alcohol?

    Yes No

    If yes, how much do you drink?

     

    Picture upload

     

    It is highly recommended that you upload a few pictures in order for the surgeon to make any specific evaluation about your request. Pictures uploaded via this form are subject to our strict privacy policy and will only be reviewed by the relevant surgeon.

    NB: Please make sure the pictures a clear. A plain background is preferred. To get the most satisfactory recommendations please provide front view, side views (right & left) oblique views (right & left) and back views of the target area if applicable.

     

    Upload picture:

    		 

    Upload picture:

    		 

    Upload picture:

    		 

    Upload picture:

    		 

    Upload picture:

    		 
    Maximum file size is 2 MB per picture.
    You can send large files via e-mail to secureimages@destinationbeauty.com.
       
    I hereby confirm that I have provided true and complete information about my medical history.
       
     
    Important notice: It may take a few minutes to upload the pictures. Please DO NOT click on the refresh, back or stop buttons in your browser. Also please DO NOT click submit or reset while the pictures are uploading.
    Contact Details:

    Hygeia Healthcare
    1st Flr., Benjamas Building
    330, 332 Charansanitwong Rd., Bang-O
    Bangplad, Bangkok 10700 Thailand

    Phone: +66 2 879 1575
    Phone (From the UK): (+44) 020 8133 8346
    Phone (From Denmark): (+45) 36 98 0111
    Phone (From USA): (+1) (323) 319 5865
    Phone (From Australia): (+61) (02) 8006 2040
    Phone (From New Zealand): (+64) 4 889 0031
    Fax: +66 2 879 1579



    E-mail: info@destinationbeauty.com

     
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