Free Plastic Surgery Assessment Online

Free Plastic Surgery Assessment.

By completing the Free Plastic Surgery Assessment Form on this page and uploading specific Assessment photos, you’re giving us the information we need to offer you your Personalised Surgical Recommendation and your Plastic Surgery quote. It also lets us know that you have read and understand CosMediTour’s Cancellation Policy and our Privacy Policy.

Assessment Form.

"*" indicates required fields

Step 1 of 3 - Personal Information

YOUR PERSONAL INFORMATION

Name*

First Last

Email*

Mobile*

Address*

Street City State Postcode Country

Date of Birth*

Day

Month

Year

Nationality*

Your Gender?*

Please provide details

Occupation*

Select Procedure*

Preferred Surgery Location*

Preferred Surgery Date*

DD slash MM slash YYYY

Your Surgery Expectations*

Do you require finance to fund your procedure?*

Yes

How did you hear about us?*

Have you contacted us before?*

This field is hidden when viewing the form

Would you be okay with us sharing your submitted photos to help other clients looking for procedure examples on their journey?*

Yes - Identity will remain anonymous & sensitive areas blurred.

No - My photos can only be added to my private & confidential client file.

This field is hidden when viewing the form

Would you be okay with us sharing your post surgery Instagram Photos?

Yes, please tag me

Yes, but do not tag me

This field is hidden when viewing the form

Please provide your Instagram Username @ handle:

YOUR MEDICAL HISTORY

Your well-being and safety are of utmost importance, so it is essential that you openly disclose any past or present medical conditions you may have.

Have you ever had any of the following?*

Anaemia

Asthma

BRCA1 Gene

BRCA2 Gene

Brain Aneurysm

Cardiovascular Disease/Condition

Crohn's Disease

Cystic fibrosis

Cancer and/or Radiation from Cancer

Diabetes Type 1

Diabetes Type 2

Dialysis

DVT (Deep Vein Thrombosis)

Taking Dexamphetamine

Ehlers Danlos

Fibromyalgia

Factor V Leiden

Heart Murmur

High Blood Pressure/Hypertension

Hepatitis

Hemochromatosis

Hidradenitis Suppurativa

HIV

Intravenous Drugs

Lumbar Peritoneal Shunt

Lupus Anticoagulant

Lithium

Marfan's Syndrome

Malignant Hyperthermia

Neutropenia

Opioids

Opioid Replacement Therapy

Pacemaker

Raynaud's

Rheumatic Heart Disease

Rheumatoid Arthritis

Scleroderma

Sjogren's Syndrome

Schizophrenia

Stoma Bag

Thyroid Condition

Thrombocytopenia

Thrombophilia

Von Willebrand

Venogenic Intracranial Hypertension

Wheelchair

None of the above

Please give further details*

What is your blood type?*

A+

A-

B+

B-

AB+

AB-

O+

O-

Unsure

Have you ever experienced Breathing Problems, Nose Surgery or Nose Trauma?*

Yes

Please give further details*

Has a direct family member of yours ever had Cancer?*

Yes

Please give further details and note which family member.*

Have you ever had any of the following?*

Anxiety

Bipolar

Borderline Personality Disorder

Body Dysmorphia

Depression

Eating Disorder

Obsessive Compulsive Disorder

Post Traumatic Stress Disorder

Schizophrenia

Other

None of the above

Please give further details*

Have you ever had another medical condition or diagnosis not listed here?*

Yes

Please give further details*

Have you ever smoked or vaped?*

Yes

How many cigarettes per day and for how long?*

If you have quit smoking, when did you quit smoking?*

Have you ever had Gastric Surgery for weight loss?*

Yes

When was the surgery?*

Are you currently taking any medications?*

Yes

Please list*

Are you currently taking any vitamins, natural remedies or nutritional supplements?*

Yes

Please list*

Please enter your current weight in kilograms.*

What best describes you?*

Please enter your goal weight in kilograms.*

Please enter your height in centimetres.*

Have you ever had another medical surgery we should be aware of?*

Yes

Please list the procedures and dates*

Have you ever had cosmetic surgery?*

Yes

Please list the procedures and surgery dates. (If previous Breast surgery, please include Implant type, placement, size, shape)*

Have you had facial injectables within the last 6 months?*

Yes

Please provide all details*

Ladies Questions

Are you currently Pregnant?*

Yes

Have you had a pregnancy in the last 12 months?*

Yes

Please give further details*

Do you have any children?*

Yes

When was the last time you breastfed?*

Please specify the Month & Year or "Never"

Are you planning on future children?*

Yes

Unsure

When do you plan to have more children (approximate time from now)?*

Current bra size:*

Desired bra size*

Desired breast outcome*

UPLOAD YOUR PHOTOS

We need very specific photos to commence your assessment. If you haven’t already done so, please take a look at our instructions that outline these requirements.

Photo Uploads

Drop files here or

Accepted file types: jpg, jpeg, gif, png, Max. file size: 12 MB, Max. files: 20.

If you have trouble uploading, please submit this form & email your photos to: [email protected]

Desired Outcome Pictures

Drop files here or

Accepted file types: jpg, jpeg, gif, png, Max. file size: 12 MB, Max. files: 3.

Please upload at least one, ideally 2-3 photo examples of your desired results. Please only use actual before and after photos from surgery websites/sources. We do not accept unrealistic model/edited/social media photos.

Do you have any questions?

PLEASE NOTE

Your personal information will be protected and handled in line with our Privacy Policy. Providing false information regarding your medical history is unsafe and may result in: a)The Surgeon's refusal to perform your surgery at any time. b) Additional costs incurred for medical treatment should post-surgery complications arise due to omitted information.

I declare that I have read and understand CosMediTour's Privacy Policy, and that I have completed this form truthfully and without purposeful omission.*

I declare that I have read and understand CosMediTour's Cancellation Policy.*