COS MEDCONNECT - Medical Evaluation Form

MEDICAL HISTORY & SURGICAL ASSESSMENT FORM

To ensure your safety and the best possible surgical outcome, please provide complete and accurate details of your medical history, including any pre-existing medical conditions. All information submitted will remain strictly confidential.

TERMS AND CONDITIONS

By submitting this form, you acknowledge and agree to the following:
- Preliminary Evaluation: This assessment is preliminary and subject to an in- person evaluation by the surgeon. COS MEDCONNECT Pty Ltd and affiliated providers reserve the right to decline surgery based on clinical findings.
- Medical Information Accuracy: You confirm that the information provided is accurate and complete. You acknowledge that failure to disclose relevant medical information may lead to procedure cancellation and associated costs.
- Additional Medical Clearances: If recommended, you agree to obtain additional medical clearances or tests prior to surgery. Non-compliance may result in procedure cancellation at your expense.
- Limitation of Liability: COS MEDCONNECT Pty Ltd, surgeons, and associated medical facilities are not liable for medical outcomes, cancellations, or financial losses resulting from undisclosed medical conditions, changes in your medical eligibility, or unforeseen medical circumstances.
- Consent to Share Information: You consent to your medical information being shared confidentially with your surgeon and medical providers overseas for the purpose of your treatment planning and medical evaluation.
- Photo Confidentiality & Usage: You consent to the confidential use of your photos for medical assessment purposes only, unless explicitly authorised for anonymised promotional or educational purposes above.
- Patient Responsibility: You acknowledge responsibility for obtaining adequate medical travel insurance and ensuring compliance with all legal and regulatory requirements in your country of residence regarding medical tourism.
Patient Information
Full Name*
Date of Birth*

DayMonthYear
Date
Gender:

MaleFemaleOther
Height:*
Weight:*
Email*
example@example.com
Phone Number*
Country of Residence
Passport Number*
Emergency Contact Information
Full Name*
Relationship to You*
Contact Number*
Medical History

Please indicate if you currently have, or have previously had, any of the following conditions (check all applicable and specify treatment details)
Cardiovascular

Heart DiseaseHypertensionPacemakerDeep Vein Thrombosis (DVT)Rheumatic Heart DiseaseHeart MurmurNone of the aboveSpecify other:
Respiratory

AsthmaCOPDNone of the aboveSpecify other:
Metabolic & Endocrine

Diabetes Type 1Diabetes Type 2Thyroid DisordersNone of the aboveSpecify other:
Neurological & Psychiatric

Epilepsy and SeizuresStrokeDepressionSchizophreniaNone of the aboveSpecify other:
Blood Disorders

AnaemiaBlood Clotting DisorderHaemochromatosisNone of the aboveSpecify other:
Immune System

HIV/AIDSHepatitisAutoimmune DiseaseNone of the aboveSpecify other:
Gastrointestinal

Crohn's DiseaseUlcerative ColitisGastric Surgery for weight lossLiver DiseaseNone of the aboveSpecify other:
Cancer History

CancerRaditation TherapyNone of the aboveSpecify other:
Other

Chronic Pain or FibromyalgiaSkin ConditionsNone of the aboveProvide details:
Health and Lifestyle Information
Do you currently smoke or vape?

NoYesSpecify daily amount:
If previously smoked/vaped when did you quit?
Current medications
List all
Do you take vitamins, supplements or natural remedies?
List all
Do you take recreational drugs (e.g.: cannabis, cocaine, MDMA, etc)?

NoYesSpecify type and frequency:
Known allergies (medications, foods, latex, etc.)
Previous surgeries
List and date
Previous cosmetic procedures
List and date
History of anaesthesia reactions or complications

NoYesProvide details:
Family history of malignant hyperthermia or anaesthetic reactions

NoYesProvide details:
Blood type

A+A-B+B-AB+AB-O+O-Unsure
Recent vaccinations (e.g; COVID-19, Hepatitis)
List all vaccinations and date
Family Medical History
Do you have children?

NoYesHow many:
Do you intend to have more children?

NoYesHow many:
Indicate any medical conditions in your family

Heart DiseaseDiabetesHypertensionCancerProvide details:
Procedure-specific Information
Procedure of Interest
Specific concerns or desired outcomes
For Breast Procedures Only
Current bra size
Desired bra size
Have you had a Mammogram?

NoYesDate:
Any history of Breastfeeding?

NoYesDuration:
For Dental Procedures Only
Have you had any of the following? (Select all that apply)

FillingsCrowns or BridgesVeneersDental implants (single, multiple, or full arch)Dentures (full or partial)Root canal treatmentTooth extractionsGum (periodontal) treatmentOrthodontic treatment (braces or clear aligners)TMJ or jaw treatment (e.g. splints, bite correction)Bone grafting or sinus liftWisdom tooth removalNone of the aboveOther:
Are you currently experiencing any of the following?

Tooth pain or sensitivityBleeding gums or gum tendernessBad breath or unpleasant tasteSwelling in the gums or faceLoose or mobile teethDifficulty chewing or biting downGaps from missing teethChipped, broken, or worn-down teethDiscoloured teeth or darkened fillingsClicking, locking, or pain in the jawHeadaches or facial tensionNone of the aboveOther:
Oral Hygiene Habits (Dental Procedures Only)
How many times per day do you brush your teeth?
How often do you floss or use interdental brushes?
Do you use mouthwash, an electric toothbrush, or a water flosser?
Oral Habits and Risk Factors (Dental Procedures Only)
Do you smoke, vape, or use tobacco products?
Do you grind or clench your teeth (bruxism)?
Do you bite nails, chew pens, or have other oral habits?
Do you have jaw clicking, locking, or use a night guard?
Have you been diagnosed with sleep apnoea or use a CPAP device?
Do you experience dry mouth or breathe through your mouth while sleeping?
Do you have acid reflux or a history of vomiting that affects your teeth?
Further details
Was an Interpreter used to assist in completing this form?

NoYesLanguage:
Do you require financing for your elective procedure?*

No - I have the financesYes - I am interested in financing
How did you hear about us?*

GoogleInstagramTikTokFacebookReferrralOther:
Photo Submission
Please submit clear photos for accurate evaluation. Photos remain confidential and are used for medical assessment only. Click the link here for tips on how to take photos.

Breast Procedures: No bra, arms relaxed by your sides.
- Front View
- Left Side View
- Right Side View
- 45-Degree Angle – Left
- 45-Degree Angle – Right
- Underbust Measurement View – measuring tape placed horizontally under the breast fold (across the base of both breasts)
Body Procedures: No clothes, bra on, arms relaxed by your sides.
- Front View
- Back View
- Right Side View
- 45-Degree Angle – Left
- 45-Degree Angle – Right
Arm Procedures:
- Front View: both arms raised to shoulder level, elbows bent at 90 degrees, palms facing forward
- Back View: both arms raised to shoulder level, elbows bent at 90 degrees, palms facing forward
- Left Side View
- Right Side View
- 45-Degree Angle – Left
- 45-Degree Angle – Right
Rhinoplasty:
- Front View
- Left Side View
- Right Side View
- 45-Degree Angle – Left
- 45-Degree Angle – Right
- Base view - Head tilted up, camera looking up at the nostrils
File Upload*

Cancelof
Consent For Photo Use
Would you be comfortable with us using your images (eyes and sensitive areas blurred) for educational or promotional purposes?*

Yes - I consent to anonymous useNo - my photos are for private assessment only
Consent and Confidentiality Agreement
By submitting this form, I acknowledge that I have read, understood, and agreed to the Terms, Conditions & Disclaimers provided at the beginning of this form.

I understand that COS MEDCONNECT Pty Ltd acts solely as a facilitator of cosmetic surgery tourism services and is not a medical provider, clinic, or licensed health practitioner.

All medical decisions must be made by a qualified medical professional. COS MEDCONNECT Pty Ltd strongly recommends that I seek a second opinion from a licensed healthcare professional in my home country before proceeding with any elective surgery overseas.
I further confirm the following*

Preliminary Consultation – I understand that this is an initial assessment for quotation purposes only and does not constitute final surgical approval. My eligibility for surgery will be determined by the surgeon following a full in-person consultation and medical reviewMedical Information & Accuracy – I confirm that all information provided in this form is accurate and complete. I understand that withholding or mis-representing medical information may result in the cancellation of my procedure or potential medical complications.Use of Personal & Medical Data – I consent to my medical information being reviewed by qualified medical professionals to assess my suitability for surgery. I understand that my personal and medical data will be handled in compliance with privacy regulations and will not be shared with third parties without my explicit consent.Photo Submission & Confidentiality – I acknowledge that any photos submitted are solely for medical evaluation. I understand that they will remain confidential and will not be shared without my permission, except where legally required.Limitation of Liability – I understand that COS MEDCONNECT Pty Ltd, it's affiliated medical providers, and associated clinics are not responsible for any costs incurred due to changes in my surgical eligibility, travel disruptions, or unforeseen medical requirements arising before or after surgery.Terms & Conditions – I confirm that I have read, understood, and agreed to the full Terms & Conditions as outlined by COS MEDCONNECT Pty Ltd.Legal Compliance – I acknowledge that my participation in this consultation is voluntary and that I am responsible for complying with any legal or regulatory requirements in my country of residence regarding medical tourism and elective procedures.
Declaration*

I declare that the information I have provided in this form is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may affect my eligibility for surgery and could result in the cancellation of my procedure.I agree to the terms and conditions.
Signature

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Date

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Patient Information

Emergency Contact Information

Medical History

Health and Lifestyle Information

Family Medical History

Procedure-specific Information

For Breast Procedures Only

For Dental Procedures Only

Oral Hygiene Habits (Dental Procedures Only)

Oral Habits and Risk Factors (Dental Procedures Only)

Further details

Photo Submission

Consent For Photo Use

Consent and Confidentiality Agreement