Online Med Questionarre - Please Allow 5-10 Seconds to Fully Load Page

First Name*
Last Name (Family Name)*
Date of Birth (Please provide CORRECT YEAR of birth)*
Gender*
- Male
- Female
Height ( Please Specify CM or Feet & Inches)*
Weight ( Please Specify Pounds or Kilos )*
Where Do You Live?*
Street Address City ZIP / Postal Code Country
Phone*
Email*
Emergency Contact Name and Phone Number (family,caregiver or close friend)*
What Treatment Are You Mainly Interested In?*
Please Describe Your Expectation of outcome*
FOR WOMEN ONLY (CHECK ALL THAT APPLY)
- I take birth control pills/hormone replacement/wear a patch.
- I am pregnant now
- I am planing more pregnancies
- I am still breastfeeding/ My breasts still have milk at this time
FOR WOMEN WITH CHILDREN ONLY

Day
Month
Year

When Did You Deliver Your Last Baby?
Have you had any surgery or been hospitalized in the past 2 years?*
- Yes
- No
If Yes, please elaborate when and cause(s).

Do You... (Choose all that apply)*
- Smoke
- Drink - Occasionally
- Drink- Everyday
- None of the above
Estimated date you would like the Treatment?
Comments or Other Requests. Please state your question(s) to surgeon if any.
How Did You Hear About Thai Medical?
- Google Search
- Bing or Yahoo Search
- Friend or Personal Referral
- TV Story or Other
Other - More Information on how your found us
If You Need To Send More Than 4 Pictures, Please Email Them To:
*******IMAGE SIZE NOTE********

Please try to attach images less than 1MB each. Larger images may cause upload/form failure. For Larger/Multiple Large images please use email instead.
Please Attach Full FRONT View Photo of the Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB.
Please Attach RIGHT Side View Photo of the Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB.
Please Attach LEFT Side View Photo of Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB.
Please Attach BACK View Photo of Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB.
If you have more pics in case of several areas concerned or are having problems uploading, please email them to Help@thaimedicalvacation.com
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