Online Medical Review - Please Allow 5-10 Seconds to Fully Load Page

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?

DD
MM
YYYY
FOR WOMEN ONLY -When did you last breast feed?

DD
MM
YYYY
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.
(.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.
(.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.
(.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.
If you have more pics in case of several areas concerned or are having problems uploading, please email them to Help@liposuctionthailand.org
GEOactual
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Online Medical Review – Please Allow 5-10 Seconds to Fully Load Page