Medical Form for Cosmetic Surgery
Full Name
*
First Name
Last Name
Contact Number
*
-
Country Code
-
Area Code
Phone Number
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you had plastic surgery (including botox & fillers)?
*
Yes
No
Do you have a history of certain diseases?
*
Yes
No
Are you taking any medication regularly or due to a certain illness?
*
Yes
No
Do you plan to visit Korea or Thailand?
*
Yes
No
Is there a hospital in Korea or Thailand you are interested in or have you consulted with before?
*
Yes
No
Please upload photos of your face from 6 angles (Front, 45 Degrees Left, 45 Degrees Right, Side Left, Side Right, Looking up) as shown in the example above
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Where did you hear about Lumeo Health?
Instagram
Facebook
TikTok
YouTube
Google
Family or friends or acquaintances
Online Group / Forum
Others
I hereby declare that all the information provided in this form is true, accurate, and complete to the best of my knowledge and belief. I understand that any false statements, omissions, or misrepresentations may result in the rejection of this form and potential legal consequences.
*
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
Continue
Continue
Should be Empty: