Online consultation form

Email (Required)

Nationality

Contact number

Name (Required)

Birthday

Sex
malefemale

Height (cm)

Weight (kg)

Emergency contact number

Address

Medical condition and history
DiabetesThyroidCardiac disorderAsthmaBlood pressureRenal diseaseLiver diseaseHematologic disorderNone

Other disease or medical condition
(Please write if have any)

Surgical history
(Please write the type of surgery and when if have any)

Medicine taking
(Please write the name of the medicine and dose per day if have any)

Allergy for medicine
NoneYes

Please write the detail if you have any allergic reaction for the medicine

Smoling
NoneYes

Please write how many(sticks per day) and how long(years) if you smoke

Drinking alcohol
NoYes

Please write how much(bottles) and how often(per month) of you drink alcohol

Desired procedure

Desired date for the surgery

Preferred surgeon

Photography
It is more helpful for surgeon if there is photo for the procedures you want. If the pictures are huge or many, compress as zip file and upload them