Fast Track Submission –

First Name*
Last Name (Family Name)*
Date of Birth (Please provide CORRECT YEAR of birth)*
Gender*
- Male
- Female
Height ( Please Specify CM or Feet & Inches)*
Weight ( Please Specify Pounds or Kilos )*
Where Do You Live?*
Street Address City ZIP / Postal Code Country
Phone*
Email*
Emergency Contact Name and Phone Number (family,caregiver or close friend)*
What Treatment Are You Interested In?*
Please Describe Your Expectation of outcome*
FOR WOMEN ONLY (CHECK ALL THAT APPLY)
- I take birth control pills/hormone replacement/wear a patch.
- I am pregnant now
- I am planing more pregnancies
- I am still breastfeeding/ My breasts still have milk at this time
FOR WOMEN ONLY – When Did You Deliver Your Last Baby?

Day
Month
Year
FOR WOMEN ONLY -When did you last breast feed?

Day
Month
Year
For Women having Breast Surgery of Tummy Tuck : How old is your youngest child? (Month&Year)
Have you had any surgery or been hospitalized in the past 2 years?
- Yes
- No
If Yes, please elaborate when and cause(s).

Do you currently or have you suffered from any of the followings Or Select "None of The Above"*
Choose ALL that apply.
If Yes to any of the above, please elaborate.
Do you have artificial implants or any metal objects in your body? If yes, please specify.
If None Type “None” or “N/A”
Do you have difficulty with healing or scarring?
- Yes
- No
If YES Please Provide More Information
Do you have any symptoms for Sensory Loss in any of your body parts?
- Upper limbs
- Lower limbs
- Pelvis Region
- Face below eyes
- Loss of smell
- None of the above
Choose ALL that apply
Please list all supplements and medications you are currently taking:*
Pls mention dosage/strength – date started & date stopped – If None Type “None” or “N/A”
Have you ever taken a MAO inhibilator, such as Naradil, Marplan or Parnate? If yes, when was your last dose?*
If None Type “None” or “N/A”
Are you Allergic to ANY medications? If yes, please elaborate
If None Type “None” or “N/A”

Do You… (Choose all that apply)*
- Smoke
- Drink – Occasionally
- Drink- Everyday
- None of the above
Estimated date you would like the Treatment?*
Comments or Other Requests. Please state your question(s) to surgeon if any.
How Did You Hear About The Liposuction Center of Thailand?
- Google Search
- Bing or Yahoo Search
- Friend or Personal Referral
- TV Story or Other
Other – More Information on how your found us
If You Need To Send More Than 4 Pictures, Please Email Them To:
******IMAGE SIZE NOTE*****

Please try to attach images less than 1MB each. Larger images may cause upload/form failure. For Larger/Multiple Large images please use email instead
Please Attach Full FRONT View Photo of the Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB.
(.jpg,.gif,.png,.pdf,.doc format ONLY)
Please Attach RIGHT Side View Photo of the Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB.
(.jpg,.gif,.png,.pdf,.doc format ONLY)
Please Attach LEFT Side View Photo of Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB.
(.jpg,.gif,.png,.pdf,.doc format ONLY)
Please Attach BACK View Photo of Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB.
If you have more pics in case of several areas concerned or are having problems uploading, please email them to Help@liposuctionthailand.org
EXPEDITED MEDICAL REVIEW FEE – HIT "SUBMIT" TO CONTINUE & FINALIZE*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Fee will be applied to future treatments. Payment Quoted in USD – Click SUBMIT to Send & Start Medical Evaluation

Allergies to food/ vaccination/ drugs/ hay fever.
Nervous Breakdown / Depression
Lung Diseases
Cancer
Tumor
Asthma
Gastrointestinal problems
Epilepsy
Liver Problems
Hepatitis A
Hepatitis B
Hepatitis C
Renal Failure
Musculoskeletal problems
Osteoporosis
Osteoarthritis
Rheumatoid Arthritis
Blood Disorders
Thrombosis
Dibetes type 1
Diabetes type 2
Thyroid disorder – overactive
Thyroid disorder – underactive
Menopause
HIV/AIDS
NONE OF THE ABOVE.

Fast Track Submission

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