Medical Tourism Pre-Assessment Form

Medical Tourism
Pre-Assessment Form

Seriously interested? Please fill up the medical tourism pre-assessment form below so we can pre-qualify and determine the best package for you. Every one is special. This is a very simple prelude to an exciting and unique medical and travel experience. Just complete the form to inform us about your previous and any current medical conditions.

After submitting the form, you will be contacted to discuss your concerns in detail and answer any of your questions. Thereafter, as the next step, you will be given a cost estimate of the medical tourism package suited for your needs.

Oops.. I forgot to tell you. There's no obligation here whatsoever. Please be patient in completing the form. Believe me, it will save us both time and effort once we get in touch with you. ;-)

Important Update: Due to management re-organization of our key facilitator, applications and inquiries for Philippine cosmetic procedures are on hold temporarily. Please watch out for better customer service announcements very soon!

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Home Phone*
Home Phone*

Medical procedure requested*
Medical procedure requested*

Age*
Age*

Sex

Height and weight

Last menstrual period (females only)

Preferred date

Will you need financing?

Past Medical History

	Hypertension
	Heart Disease
	Bronchial Asthma
	Tuberculosis
	Diabetes Mellitus
	Cancer
	HIV (Aids)
	Hepatitis
	Thyroid problems
	Kidney problems
	COPD (Emphysema or Chronic Bronchitis)

Smoking? How many sticks per day and duration

Alcohol history (number of shots per day)

History of drug abuse

History of tattoing

Current Medications (vitamins, maintenance, medications,inhalers, supplements)

Previous surgery (date and name of procedure, complications)

Previous blood transfusion

Allergies (food or medications)

Previous cosmetic / aesthetic surgery (date and name of procedure, complication)

Bleeding History (if with history of bleeding on previous surgery, dental procedures)

Previous Anesthesia experience (what kind? Any complications)

Previous Hospitalization (inquire date and reason for confinement)

Provide any recent medical laboratories / examination if any:

Any other medical information?

How did you hear about us?

Please enter the word that you see below.

Please don't forget that spaces marked with the asterisk are required fields. Thank you!

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