Please take a few moments to complete this form with accurate information to support your health assessment. Providing honest details ensures your safety and suitability for surgery. All records and photos are kept strictly confidential to protect your privacy.
We’ll be in touch once we receive your form.
Medical History Screening: Your medical history is used for initial screening; final approval is made by your surgeon.
Candidacy Assessment: Surgery may be declined if you’re not medically suitable.
Additional Consultations: If further checks are required and declined, surgery may be cancelled (pre-check costs still apply).
Travel Expenses: Travel and accommodation expenses are the patient’s responsibility.
Preliminary Information: Information provided is for assessment only; final outcomes depend on your in-person consultation and individual condition.
