Free Cosmetic Assesment

Personal Information
Contact Information
Travel Information
Treatment & Health condition
Lifestyle Health History

Please have your photographs ready to be attached prior to filling out the Online Assessment Form.

Click here to see the photographs guide

Personal Information

Title

First Name*

Last Name

Date of Birth*

Gender

Nationality*

How did you hear about us?Internet SearchSocial MediaReferral / Word of MouthOther

Contact Information

Address*

Suburb*

State / Province / Region*

ZIP / Postal Code*

Postal Address*

Email Address*

Mobile Phone*

Emergency Contact (Not travelling with you)

First Name*

Last Name

Phone (Home)

Mobile Phone

Relationship to Emergency Contact

Travel Information

Your Financial Support

Preferred Destination*

Preferred Date of Departure Not sure about the travel date

Departure Airport

Travel Companion Details

Title

First Name

Last Name

Tel (Mobile)

Comments / Questions (if any)

Lifestyle Health History

Photographs Required

PHOTOS ARE REQUIRED to secure a surgical recommendation. Make sure you have looked at the correct examples which are found here on:

PROCEDURES

FACE & EYE

NOSE

EAR

TUMMY

BREAST

ARMS

Image upload*

IMAGE LOADING: If you are having problems uploading your images onto this form, submit the form and email images separately to: info@medicaltravel.com.au

Any questions for AMT?

Cosmetic Online Assessment Form

Please have your photographs ready to be attached prior to filling out the Online Assessment Form.

Personal Information

Contact Information

Contact Information

Emergency Contact (Not travelling with you)

Travel Information

Travel Companion Details

Treatment & Health condition

Family Medical Conditions

Please answer using the following. If YES - Please specify

Habits

Lifestyle Health History

Photographs Required

IMAGE LOADING: If you are having problems uploading your images onto this form, submit the form and email images separately to: info@medicaltravel.com.au

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