Evaluation Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Nationality
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height (cm)
Weight (kg)
What procedure are you interested in?
Sex Reassignment Surgery
Facial Feminization Surgery
Body Contouring Surgery
Hair Transplant
Other
What results are you after?
When do you plan to have the surgery done?
ASAP
2021
2022
No plan as yet
Anything else we can help you with?
Upload your concerned areas pictures
Browse Files
Drag and drop files here
Choose a file
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Medical Condition - Yes or No. If yes, please specify medication/treatments.
*
Rows
No
Yes
Specify condition/history/treatments
Diabetes
Hight blood pressure
Heart problems
Lung problems
Kidney problems
Liver problems
Current or previous history of DVT/PE
Blood disorders
Hepatitis
Anesthesia problems
Nervous breakdown/depression
Others
Medical History - Yes or No. If yes, please specify
*
Rows
Yes
No
Specify condition/history/treatments
Have you ever had any surgery/plastic surgery before?
Do you have any implants in your body?
Do you smoke? If yes, how many cigarette per day?
Do you drink alcohol? If yes, how often?
Are you allergic to any drugs or foods?
For Sex Reassignment Surgery
Rows
Please explain
When did you start Full-Time Real Life Test (RLT)
When did you star hormones therapy?
List the name of hormone(s) you are on.
Do you have a psychiatrist, psychological social worker or clinical psychologist? Specify their names.
How often do you meet your therapist?
Would your therapist be happy to provide a letter/medical certificate including a treatment history?
Are you circumcised?
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