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Home > Make An Enquiry > Medical Form

Get a surgical recommendation / quote now

Medical Form

Please take a few moments to fill in our form and provide essential information as indicated below. Accurate information is necessary for your health assessment. A false declaration may result in rejection of treatment and / or surgery by your surgeon at the time of consultation after your arrival. All the health records and photographs of patients are kept highly confidential to ensure complete privacy and anonymity of the patient.

When we receive your information, we will respond to your email within 24 – 48 hours. If you do not receive a response within 48 hours, please notify us.

Terms and Conditions:

Your medical history is used for primary screening/evaluation before seeing our doctor. The doctor will decide whether to consider your medical history. If the patient was advised to visit their doctor for personal consultation and pre-operative tests and it was found out later that they were not a suitable candidate or they were not physically fit to have the surgery for any valid reason, the hospital/doctor has the right/authority to refuse the case.
If the plastic surgeons advise/recommend the patient to see another doctor for additional consultation before the surgery and the patient refuses to do so, the attending plastic surgeon has the right to cancel the surgery. The patient will be charged for pre – check up costs as per the package price. For these reasons, the hospital/doctor/RBG will not be liable for the flight/travel, accommodation expenses of the patient during his/her trip.
All submitted personal information and client expectations will serve as premilinary information for consultation only, and final results after surgery will largely depend on the client’s pre-existing structure and physique, which can be fully comprehended by a surgeon only upon actual consultation and physical examination at the hospital.

Medical Form - RBG

Patient Information
Preferred title*
First Name (As shown on passport)*
Surname (As shown on passport)*
Passport Number
Gender*
- Male
- Female
Nationality*
Date of Birth*
DD slash MM slash YYYY
Blood group
Weight (kg)*
Height (cm)*
Telephone number*
E-mail address*
Address*
Suburb*
City*
State*
Postcode*
Country*
Person to notify in case of emergency *
Next of Kin: First Name and Surname*
Next of Kin: Telephone*
Initial Health Screening
1. Your Family History
Heart disease*
- No
- Yes
Diabetes*
- No
- Yes
Hypertension*
- No
- Yes
Asthma*
- No
- Yes
Other diseases not mentioned
- No
- Yes
If Yes, please provide details
Cancer in the family*
- No
- Yes
If Yes, please specify position
Multi-diseases in the family*
- No
- Yes
If Yes, please specify position
Abnormal history of anaesthesia*
- No
- Yes
If Yes, please provide details
2. Your Past medical history and treatment
Heart disease*
- No
- Yes
Post stent (date)
MM slash DD slash YYYY
Post bypass (date)
MM slash DD slash YYYY
Diabetes*
- No
- Yes
Hypertension*
- No
- Yes
Deep vein thrombosis*
- No
- Yes
Cardiovascular disease*
- No
- Yes
Asthma*
- No
- Yes
Hyperthyroidism*
- No
- Yes
Hypothyroidism*
- No
- Yes
Adrenal insufficiency*
- No
- Yes
Hepatitis B*
- No
- Yes
HIV*
- No
- Yes
Keloid scarring*
- No
- Yes
Multiple sclerosis*
- No
- Yes
Cancer*
- No
- Yes
If Yes, please specify position
Past Surgical History*
- No
- Yes
If Yes, please list name of Procedure and Date
Have you ever experienced excessive bleeding after accident, surgery, labour or dental procedure?*
- No
- Yes
3. Underlying Disease
3. Underlying Disease/s at present*
- No
- Yes
If Yes, please provide details
3.1 Skin Infection*
- No
- Yes
If Yes, please provide details
3.2 When was your last menstrual Period*
- Not Applicable
- Enter Date
Please provide details (days)*
3.3 Are you currently taking the contraceptive pill?*
- No
- Yes
If Yes, please provide details
4. Drug Allergy*
- No
- Yes
If Yes, please provide details
5. Food or Health Products Allergy*
- No
- Yes
If Yes, please provide details
6. Current medications being taken
1. Current medications being taken
2. Current medications being taken
3. Current medications being taken
4. Current medications being taken
7. Habit History *
Smoking*
- No
- Yes
If Yes, please provide details
Drinking*
- No
- Yes
If Yes, please provide details
Breast Surgery Information - If Applicable
This is only required if you are having a Breast Augmentation procedure. Final details will be discussed with your Plastic Surgeon at your physical consultation.
Current Bra size
Requested Size
- Requested Size
- Unsure
Your Requested Size
Desired Placement
- Under the muscle
- Front of the muscle
- Unsure
Desired Implant Type
- Silicone Round
- Silicone Tear Drop
- Unsure
Desired Incision
- Armpit
- Under breast crease
Have you had a Mammogram? (Patients over 40)
- No
- Yes
Results
Have you breastfed
- No
- Yes
Last date you breastfed
Age of last child
Pre-Surgical / Anaesthesia
Do you use aspirin, NSAIDs (Motrin, Aleve, etc.), or any derivatives?*
- No
- Yes
Do you use blood thinners (Coumadin/Warfarin, Heparin, Lovenox)?*
- No
- Yes
If Yes, Please specify medication name
Have you used diet pills in the last two weeks?*
- No
- Yes
If Yes, Please specify medication name
Have you taken steroids within the last year?*
- No
- Yes
If Yes, Please specify medication name
How long
Have you ever taken Accutane?*
- No
- Yes
If Yes, when was you last dose?
Have you or your immediate family members had any reactions?
1. Problems or complications associated with anaesthesia*
- No
- Yes
If Yes, please specify
2. Do you or your family have malignant hyperthermia?*
- No
- Yes
If Yes, please specify
Acknowledgement
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Restored Beauty Getaways/Hospital/Clinic of any change in my medical status. I also authorise the health care staff to perform the necessary pre-operative services I may need.
- I am willing to accept the terms and conditions stated above
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