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Free surgery opinion from Dr Boonchai
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Free surgery opinion from Dr Boonchai
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Personal Information
Name
*
*
Gender
*
Male
Female
Date of Birth
*
Email
*
Phone
*
Address
*
Height (cm.)
*
Weight (kg.)
*
Preferred Surgical Date
Travel Date (from)
Travel Date (To)
Are you Traveling with Someone ?
Travel Partners Name
Family History
Family Heart Disease ?
*
Yes
No
Family Diabetes ?
*
Yes
No
Family Hypertension ?
*
Yes
No
Family Asthma ?
*
Yes
No
Family Cancer ?
*
Yes
No
Personal History
Heart Disease
*
Yes
No
Diabetes
*
Yes
No
Hypertension
*
Yes
No
Deep Vein Thrombosis
*
Yes
No
Cardiovascular Accidents
*
Yes
No
Asthma
*
Yes
No
Bleeding Tendency
*
Yes
No
Hyperthyroidism
*
Yes
No
Hepatitis
*
Yes
No
HIV
*
Yes
No
Keloid Scarring
*
Yes
No
Cancer
*
Yes
No
Major Operation
*
Yes
No
Underlying Disease
*
Yes
No
Drug Allergies
*
Yes
No
Food Allergies
*
Yes
No
Ever treated for Depression
*
Yes
No
Other Medications & Dosage
List all medications you currently take including dosage for each
*
Current Vitamins, food/nutritional supplements
Do you Smoke?
*
Yes
No
Do you Drink ?
*
Yes
No
Birth Control? Please Specify
Are you Pregnant now?
*
Yes
No
Planning for more pregnancies ?
*
Yes
No
Age of Youngest Child
Last Breastfed - Month & Year
For Breast implants
Desired Size Post Surgery
Desired Outcome Post Surgery
Placement
Implant
Desired Incision
Previous Breast Augmentation ?
Surgery Procedure
*
Face / Neck Lift ( Rhytidectomy )
Coronal Brow Lift
Endoscopic Brow Lift
Fat transfer (Fat injection) (include liposuction) GA* start from
Lower face & Neck lift
Middle&Lower face & Neck lift
Full face lift (Coronal Brow Lift+Middle +Lower Face Lift+Neck Lift)
Direct Brow Lift GA*
Neck lift
Eyelid Correction ( Blepharoplasty)
Upper or Lower eyelid LA
Upper or Lower eyelid IV sedate
Upper and Lower eyelid IV Sedate
Upper or Lower eyelid GA*
Upper and Lower eyelid GA*
Upper and Lower eyelid LA
Upper or Lower eyelid
Upper and Lower eyelid
Nose
Alar reduction
Asian Nose Augmentation with silicone implant
Breast Surgery Breast Augmentation
Breast Augmentation : Round Implant
Breast Augmentation : Tear drop Implant
Endoscopic Breast Augmentation : Round Implant
Endoscopic Breast Augmentation : Tear drop Implant
Fat transfer (Fat injection) (include liposuction) start from
Revision Breast Implants
Capsule removal + implants replacement
Breast Lifting with implants (Round shape implant)
Vertical-scar Breast Lift with implants (moderate ptosis)
Vertical-scar Breast Lift/Reduction with implants (severe ptosis)
Vertical-scar Breast Lift with implant replacement
Unilateral breast lift, Unilateral BA
Breast Lifting/Reduction without implants
Vertical-scar Breast Lift
Vertical-scar Breast Reduction
Nipple
Nipple Reduction 2 sides GA*
Nipple Reduction 2 sides LA
Male Breast Reduction
Breast glandular excision
Breast glandular Excision and Liposuction both chest
VASER Liposuction
Ultrasound Liposuction, First area
Ultrasound Liposuction, First area, GA *
Ultrasound Liposuction, beyond first area (per area)
Body Contouring
Mini Abdominoplasty
Abdominoplasty (TummyTuck)
Abdominoplasty (TummyTuck) with Liposuction both hips
Extended Abominoplasty (TummyTuck)
Brachioplasty (Arm lift)
Extended Abdominoplasty with Liposuction both hips
Thigh Lift (Horizontal)
Thigh Lift (Vertical or Extended)
Cosmetic Female genital surgery
Labia minora reduction GA*
Labia minora reduction
Vaginal Tightening GA*
Vaginal Tightening
Sex Reassignment Surgery (SRS)
Male to Female : Penile Skin Inversion + Scrotal Skin Graft
Sex Reassignment Surgery (SRS)
Male to Female : Penile Skin Inversion + Scrotal Skin Graft
Others
Scalp advancement (Hair line reduciton surgery)
Hair Transplantation (70/unit) start from 1000 units
What results do you expect ?
(Please describe to the surgeon what you looking for)
Attach Your Photo
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Please send your photos for Dr Boonchai’s review and assessment.If you have a problem about upload the photos , please contact our staff info@doctorboonchai.com A photo file size should be less than 5MB.
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Example Standard photography.
Legal Agreement
Agreement
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I hereby certify that the above statements are true and correct to the best of my knowledge.
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