Call Us Now: +66 2 8791575
Email: info@destinationbeauty.com

Facelift

Liposuction

Tummy Tuck

Sex Change

Total Makeover

Mommy Makeover

Dental Care

Hair Transplantation

LASIK Eye Surgery

Medical Questionnaire

Select Language

Thank you for your inquiry with Destination Beauty. We will send you an e-mail with a brochure for your requested procedure(s). Please check your Inbox or Junk Mail for our reply .

You can now proceed to step 2 right away and complete our medical questionnaire below to find out if you are a likely candidate for your requested procedures.

Complete inquiry form
Complete medical questionnaire form
Complete booking form

Your questionnaire and pictures will be reviewed by the relevant surgeon who will evaluate whether you are likely to be a candidate for your requested procedure(s). Please submit questionnaire and pictures at the same time!

All fields must be completed before submitting the form.

First Name (As Appears In Passport):
Last Name (As Appears In Passport):
E-mail:
Phone:
Gender:	Male Female
Age:
Date of Birth (MM.DD.YYYY):
Passport Number:
Weight:
Height:
Nationality:
Address:

PERSON TO CONTACT IN CASE OF EMERGENCIES
Name
Email
Phone
Address:

SURGERY DETAILS
Planned Date of Surgery:	Flying home on date:
What procedures do you require?
What results do you expect? (Please be as specific as possible)
Please specify the surgeon if any:
	Click to see surgeon profiles
Questions to Surgeon


MEDICAL CONDITIONS (Please specify yes or no by clicking the box)
	Yes	No
Diabetes or blood sugar problems
Thyroid problems
Heart problems
Lung problems; e.g. asthma or other breathing difficulties
Blood pressure problems (hypertension)
Kidney or liver problems
Blood disorders
Previous or current history of cancer
HIV or AIDS
Nervous Breakdowns/Depression
Neurologic problems
Anesthesia problems

If you have answered YES to any of the above, please specify:
Have you had or do you have any medical conditions not mentioned above? Yes No
If yes, please specify:

FOR WOMEN:
Do you take birth control pills or any hormone replacement medication or hormone patch?
Are you pregnant?
Are you planning any more pregnancies?
When did you last deliver a baby?
When did you last breastfeed?

MEDICAL HISTORY
	Yes	No
Have you been hospitalized, had surgery or received medical care within the past 12 months?
If yes, when?
If yes, what was the reason for this?
Do you have implants or any metal objects in your body?
If yes, please specify:
Do you have difficulty with healing or scarring?
Do you have any allergies to food, drugs, etc?
If yes, please specify:
List all medications you currently take including dosage for each:
List all vitamins or food/nutritional supplements you currently take:
Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?
If yes, when was your last dose?
Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin?
If yes, when was your last dose?
Do you smoke?
If yes, how much do you smoke?
If yes, when did you last smoke?
Do you drink alcohol?
If yes, how much do you drink?

Picture upload It is highly recommended that you upload a few pictures in order for the surgeon to make any specific evaluation about your request. Pictures uploaded via this form are subject to our strict privacy policy and will only be reviewed by the relevant surgeon.

NB: Please make sure the pictures a clear. A plain background is preferred. To get the most satisfactory recommendations please provide front view, side views (right & left) oblique views (right & left) and back views of the target area if applicable.

Upload picture:
Upload picture:
Upload picture:
Upload picture:
Upload picture:
Maximum file size is 2 MB per picture. You can send large files via e-mail to secureimages@destinationbeauty.com.

I hereby confirm that I have provided true and complete information about my medical history.

Important notice: It may take a few minutes to upload the pictures. Please DO NOT click on the refresh, back or stop bottons in your browser. Also please DO NOT click submit or reset while the pictures are uploading.

Contact Details:

Hygeia Healthcare Co. Ltd.
1st Flr., Benjamas Building
330, 332 Charansanitwong Rd., Bang-O
Bangplad, Bangkok 10700 Thailand

Phone: +66 2 879 1575
Phone (From the UK): (+44) 020 8133 8346
Phone (From Denmark): (+45) 36 98 0111
Phone (From USA): (+1) (323) 319 5865
Phone (From Australia): (+61) (02) 8006 2040
Phone (From New Zealand): (+64) 04 889 0031
Fax: +66 2 879 1579

E-mail: