• 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

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

Heart Disease
Diabetes
Hypertension
Asthma
Cancer
Others
IMPORTANT NOTE: Information below is important for your Surgical Recommendation. If you are under medical care, please state all condition/s current and preexisting.
The Surgeon may request further information &/or your medical professionals’ letter stating you are fit for surgery, before any final evaluation is given. Omitting any information could result in surgeon rejecting surgery at the time of face-to-face consultation.

Habits

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 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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