Online Consultation & Photo Review Form

First Name

Last Name

MOBILE NUMBER

Home Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Postal Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

ID NUMBER

PASSPORT NUMBER

DATE OF BIRTH

AGE

OCCUPATION

RELIGION

HEIGHT

WEIGHT

NEXT OF KIN NAME

First

Last

NEXT OF KIN NUMBER

WORK NUMBER

FAX NUMBER

GENDER

ETHNICITY

HOME LANGUAGE

MARITAL STATUS

HOW DID YOU HEAR ABOUT US

REFFERRING PHYSICIAN NAME

First

Last

REFFERRING PHYSICIAN CONTACT NUMBER

I AM INTERESTED IN THE FOLLOWING PROCEDURES

Sign me up for special deals and offers with WM Aesthetics.

Yes

Do you have a bleeding disorder or do you ever suffer form excessive bleeding?

Have you ever had high blood pressure?

Have you ever had a blood transfusion?

Have you ever had a stroke, heart attack or angina?

Have you ever had a heart murmur?

Have you ever had an ECG?

Do you suffer from Asthma or ever had any breathing problems?

Do you suffer form Lupus?

Have you ever been diagnosed with Cancer?

Do you suffer from Fibromyalgia?

Do you suffer from Arthritis?

Do you suffer from Scleroderma?

Do you have AIDS/ HIV/ Tuberculosis?

Do you have any Thyroid related problems?

Do you have any kidney related problems?

Do you have any Gallbladder related problems?

Do you have any Stomach problems e.g.. previous or current ulcer?

Have you ever suffered from bowel or urinary problems?

Do you suffer from any abnormalities of the Nervous System eg epilepsy?

Have you ever used any anti-depressant/ anxiety treatment/ mental health medication?

Have you ever seen a psychiatrist or psychiatric councillor?

Have you ever suffered from Jaundice or Hepatitis A, B or C?

Have you suffered from neck, back, muscle or joint problems?

Do you suffer from Diabetes?

Have you ever had any problems with wound healing such as keloid scarring?

Do you suffer from any other serious illness?

Do you smoke?

Do you drink more than 3 cups of coffee or green tea per day?

Do you drink alcohol?

Antibiotics

Anti-inflammatories

Arthritis medication

Aspirin

Birth Control Pills

Bufferin

Cortisone/ Steroids

Cough Medicine

Dilantin

Hormones

Insulin/Diabetes medication

Iron

Motrin

Phenobarbital

Sleeping Pills

Water Pills

Bloodthinners eg:

Blood Pressure Pills

Thyroid medication

Vitamin E

Warfarin or Heparin

Do you take ANY other medication?

Do you have any allergies?

Have you ever had local/ general anaesthetic/ sedation?

If YES, please list full details

Have you ever had an adverse reaction to a local/ general anaesthetic/ sedation?

Did you ever have any post-operative complications?

Have any of your blood relatives had:

Arthritis

Diabetes

Bleeding Disorder

Cancer

Are you planning a holiday in the near future?

Photographs are critical in determining if you are a good candidate for surgery. It is important that you upload good quality photos that adequately demonstrate the areas of concern. You will not be considered for a virtual consultation if your photos are missing or inadequate. Below are some tips for providing good quality photos: Provide proper lighting Photos against a solid color wall are preferred but not required The best quality photos are taken by another person. Please do not submit “selfies” as they often have poor lighting, poor angles, or do not adequately show the areas of concern. You can also use your own self timer on your phone. Photos should be recent.

Photo views to submit:

Front view

Side View Right

Side View Left

Diagonal View

Posterior/Back

Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 8 MB.

Disclaimer

I confirm that the above health history is accurate and complete. I understand that withholding any medical information will be detrimental to my health and safety during the procedure that the surgeon agrees to undertake.

Consent

I consent to the disclosure of sensitive personal data to relevant doctors, surgeons, nurses and other health professionals for the purpose of discussing any surgical or medical procedure concerning myself.