Online Assessment Form Thailand

Let’s get started

Your Free Assessment

Starting your journey is easy. Just complete this 5 minute form to receive your obligation-free quote. You’ll need some photos to upload, so before you start take a look at our how to photo guide and have your photos ready.

If you have any questions, we’re here to help on 1300 000 633.

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How To Take Your Photos

All Procedures

Breast

Body

Face

Male

Let's Begin

We’re about to ask some personal questions. We appreciate that this might seem confronting, but we need his information get a complete picture of who you are so that we can offer you the very best solution.

Please rest assured that your privacy is important to us, and your information will remain confidential.

"*" indicates required fields

Step 1 of 4 - Personal Information

YOUR PERSONAL INFORMATION

Name (as it appears in your passport)*

First Last

Email*

Mobile*

Address*

Street City State Postcode Country

Date of Birth*

Day

Month

Year

Gender*

Nationality*

Occupation*

Select Procedure*

Preferred Surgery Location*

Preferred Surgery Date*

DD slash MM slash YYYY

Your Surgery Expectations*

Would you like to apply for finance for your procedure?*

Yes

How did you hear about us?*

Google Search

Word of Mouth

Instagram Account

Instagram ''Advertisement"

Facebook Account

Facebook ''Advertisement"

Online Forum

YouTube

Walk In

Newspaper or Magazine

Television

Other

YOUR MEDICAL HISTORY

Please Note: Providing accurate medical information is important for your surgical recommendation Please ensure that you state all medical conditions, both current and pre-existing. Your Surgeon may request further information or your medical professionals’ letter stating you are fit for surgery before a final evaluation is provided. Omitting any information could result in your Surgeon rejecting surgery at the time of your face-to-face consultation.

Have you had any of these Medical Conditions?*

Diabetes

DVT (Deep Vein Thrombosis)

Asthma

Thyroid Condition

Cardiovascular Disease / Condition

Heart Murmur

Anaemia

Crohns Disease

Rheumatoid Arthritis

High Blood Pressure / Hypertension

Hepatitis

HIV

None of the above

Please give further details*

Do you have any Allergies to Medicines, Dressings, Antiseptics, or Latex?*

Yes

Please give further details*

Do you have any food allergies?*

Yes

Please give further details*

Have you ever experienced Breathing Problems, Nose Surgery or Nose Trauma?*

Yes

Please give further details*

Have you ever had Cancer?*

Yes

Please give further details*

Has a direct family member of yours ever had Cancer?*

Yes

Please give further details and note which family member.*

Have you ever been diagnosed with a mental health condition such as: Anxiety, Depression, PTSD, Bipolar, Personality Disorder, Schizophrenia, Body Dysmorphia, Other?*

Yes

Please give further details*

Have you ever been diagnosed with an eating disorder?*

Yes

Please give further details*

Have you ever had another Medical Condition or Diagnosis not listed here?*

Yes

Please give further details*

Have you ever used Intravenous Drugs or received Opioid Replacement Therapy?*

Yes

Please give further details*

Have you ever Smoked Cigarettes?*

Yes

How many cigarettes per day and for how long?*

If you have quit smoking, when did you quit smoking?*

Have you ever had Gastric Surgery for weight loss?*

Yes

When was the surgery?*

Are you currently taking any Medication?*

Yes

Please list*

Are you currently taking any Vitamins, Natural Remedies or Nutritional Supplements?*

Yes

Please list*

Please enter your current Weight in Kilograms.*

Describe your current weight*

Underweight

Acceptable Weight

Overweight

Please enter your goal Weight in Kilograms.*

Please enter your Height in Centimetres.*

Have you ever had another Medical Surgery we should be aware of?*

Yes

Please list the procedures and dates*

Have you ever had Cosmetic Surgery?*

Yes

Please list the procedures and dates*

Have you had facial BOTOX or Filler within the last 6 months?*

Yes

Please provide all details*

Have you ever had Breast Surgery?*

Yes

Please provide all details*

Ladies Questions

Are you currently Pregnant*

Yes

Do you have any Children?*

Yes

When was the last time you Breastfed?*

Please specify the Month & Year or "Never"

Are you planning on Future Children?*

Yes

Unsure

When do you plan to have more children (approximate time from now)?*

Current bra size:*

Desired bra size*

Desired breast outcome*

SHARING YOUR PHOTOS

Would you be okay with us sharing your submitted photos to help other clients looking for procedure examples on their journey?*

Yes - Identity will remain anonymous & sensitive areas blurred.

No - My photos can only be added to my private & confidential client file.

Would you be okay with us sharing your post surgery Instagram Photos?

Yes - Please tag me

Yes - Anonymously

Please provide your Instagram Username @ handle:

UPLOAD YOUR PHOTOGRAPHS

We need very specific photos to commence your assessment. If you haven’t already done so, please take a look at our instructions that outline these requirements.

Photo Uploads

Drop files here or

Accepted file types: jpg, jpeg, gif, png, Max. file size: 12 MB, Max. files: 20.

PHOTO ISSUES If you have any trouble uploading your photos, simply submit this form and email your photos to us at [email protected]

Do you have any questions?

Client Consent & Declaration

Please note that false declarations in relation to any of your medical conditions or history may result in; the Surgeon rejecting surgery at the time of your consultation, after your arrival at the hospital, and/or additional costs to the client if there are any post surgery complications that require additional medical attention and hospitalisation due to omissions in the information. All personal information is confidential and is not released to any other individual, party, individual or organisation without the consent of the client. Also please refer to the Website CosMediTour Terms & Conditions & Disclaimer. Full terms, conditions & disclaimer will be issued upon acceptance of surgery after your evaluation has been received.

I declare that I have truthfully completed this Personal, Medical and Consent Form, without any purposeful omissions.*