Virtual Consultation Personal Information Contact Information Medical Information Medical Condition Medical History Web Site First Name Last Name Email Date of Birth Gender Female Male Age Nationality Passport Number Preferred Language Preferred Language Arabic Burmese Cambodian Chinese English Filipino French German Italian Japanese Korean Malayu Russian Spanish Thai Vietnamese Contact Number Height (cm) Weight (kg) Address * Address Line 2 Town/City State/Province/Region Postal Code Country Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People 's Republic of China Republic of China Christmas Island Cocos(Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea - 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Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Person to Contact in Case of Emergency First Name Last Name Contact Number Email Address * Address Line 2 Town/City State/Province/Region Postal Code Country Country Afghanistan Åland Islands Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Surgery Details Planned Date of Surgery Flying Home On What procedures do you require? What results do you expect? (Please be as specific as possible) Questions to Surgeon Diabetes or blood sugar problems * Yes No Heart Problems * Yes No Blood pressure problems * Yes No Blood disorders * Yes No HIV or AIDS * Yes No Previous history of Deep Vein Thrombosis (DVT) or Pulmonary Embolism * Yes No Neurologic problems * Yes No Thyroid problems * Yes No Lung problems * Yes No Kidney or Liver problems * Yes No Previous/current history of cancer * Yes No Nervous Breakdowns/Depression * Yes No Anesthesia problems * Yes No If you 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 (For Women having Breast Surgery or Tummy Tuck) Have you undergone any surgical means of birth control (e.g. Tubal Ligation)? Yes No How many children have you had? How old is your youngest child? (Month & Year) Have you ever breastfed? Yes No When did you last breastfeed? (Month & Year) Do your breasts still have milk at this time? Note: Lactation may also be included by other factors such as hormone intake. Please test by squeezing breasts. Yes No Have you ever been hospitalized or received medical care in the past 12 months? Yes No If yes, when? If yes, what was the reason for this? Have you had any surgery before? Yes No If yes, when? If yes, what kind? Do you have fillers, implants or any metal objects in your body? Yes No If yes, please specify what & when this was inserted/injected: Do you have any 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? Only send photos of the body part for which you are seeking plastic surgery. Affirmation Statement * I hereby certify that all the information above are true and correct.
