MQ - Plastic Surgery Phuket

The first and most essential step to a successful surgery is for doctor to learn as much about patient as possible. This Medical Questionnaire helps our plastic surgeons determine if you are medically qualified for your surgery.

Remember there is no obligation once an estimate is created.
First Name
As in passport
Last Name
As in passport
Email*
Date of birth*
Phone*
Nationality
Height
Weight
- Male
- Female
When did you last deliver a baby?
(Month and Year)
When did you last breast feed?
(Month and Year)
Are you pregnant now?
- Yes
- No
Do you take birth control pills?
- Yes
- No
Planning any more pregnancies?
- Yes
- No
Current Bra Size
Desired Implant
Requested Size
Desired Incision
Desired Placement

After you fill out the Questionnaire, a plastic surgeon from your preferred hospital will carefully review your case and prepare an initial evaluation, including a price quote for procedure(s) of your choice.
Select preferred surgery
Other surgeries
example: liposuction, tummytuck, etc.
What results do you expect?
Preferred location and hospital
Current Bra Size
Requested Size
Desired Placement
Desired Implant
Desired Incision
Preferred surgery date

Can be approximate

Taking & submitting photographs:

To allow a cosmetic surgeon to make the most comprehensive assessment of your case and provide the best possible recommendation for your surgery, please do your best to take your photographs in the following format.
- Use solid background
- Take one frontal photo of your chest, body or face, centered and looking forward
- Take at least one, preferably two profile (side view) photos, at either right or left angle
- Take one photo of your back, if needed
Your photographs are kept in strict confidence and only shared with doctors who are assigned to handle your medical procedure.
NEXT*
- I want to upload pictures now
- I will send pictures later by email
Upload Pictures for Medical Evaluation by the Surgeon*
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, bmp, webp.
Comments
This field is for validation purposes and should be left unchanged.

Beauty Med (Thailand) Co., Ltd | Thailand Office +(66) 2 653 3880 | Australia Office +(02) 800 500 56