Page 1 of 1

Client Intake Form

Full name (as in passport)

*

Email address

*

Country of residence

*

WhatsApp number

*

Procedure(s) of interest

*

Have you had previous surgeries?

*

Any health condition(s)

*

Any health condition(s)

Hypertension

Heart disease

Diabetes

Deep vein thrombosis

Asthma

Bleeding tendencies

Cancer

Hyperthyroidism

HIV

Hepatitis

Keloid scarring

Other

Don't have any health condition

Any medical conditions or allergies

*

Current medications

*

Do you smoke cigarette, vape etc.?

*

Do you smoke cigarette, vape etc.?

A

Yes

B

No

Do you drink alcohol?

*

Do you drink alcohol?

A

Don't drink

B

1-2 times/week

C

3 times or more/week

Preferred travel dates

*

Traveling alone or with a companion?

*

How did you hear about us?

*

Photo Upload

Joint replacement: X-Ray/CT/MRI, IVF/ICSI: Hormone or other related test, Plastic Surgery: picture of body part (front, back, both sides)

Size limit: 10 MB

Primary Contact

*

Primary Contact Phone Number

*

Client Intake Form

Full name (as in passport)

Email address

Country of residence

WhatsApp number

Procedure(s) of interest

Have you had previous surgeries?

Any health condition(s)

Any medical conditions or allergies

Current medications

Do you smoke cigarette, vape etc.?

Do you drink alcohol?

Preferred travel dates

Traveling alone or with a companion?

How did you hear about us?

Photo Upload

Primary Contact

Primary Contact Phone Number

Any questions or special requests