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Free Cosmetic Surgery Assessment

Please complete the NipTuck Plastic Surgery Medical Form and submit the required photos. This will allow us to ensure the right NipTuck Plastic Surgeon can assess your individual needs and provide personalised recommendations and pricing- all non-obligation.

Personal Details

Please complete this form truthfully. A false declaration may result in rejection of treatment and/or surgery. All information is strictly confidential.

GenderRequired

Please enter height in cm (e.g. 162) and weight in kg (e.g. 68). Both are required to calculate BMI for surgical assessment.

Which procedure are you asking about?Required

Past Medical History

Heart Diseases
Diabetes
Hypertension
Deep Vein Thrombosis
Cardiovascular Accidents
Asthma
Bleeding Tendency
Hyperthyroidism
Hypothyroidism
Adrenal Insufficiency
Hepatitis B
HIV
Keloid Scarring
Multiple Sclerosis
Cancer

Past Surgical History (list procedure & date)

Excessive bleeding after accident, surgery, labour or dental procedure?

Current Conditions & Medications

Skin Infection at present

Allergies

Drug Allergy
Lidocaine (with or without adrenaline)

Pre-Surgical / Anaesthesia

Aspirin, NSAIDs (Motrin, Aleve etc.) or derivatives?
Blood thinners (Coumadin/Warfarin, Heparin, Lovenox)?
Diet pills in the last two weeks?
Steroids within the last year?
Ever taken Accutane?
Problems or complications with anaesthesia?
Family history of malignant hyperthermia?

Habit History

Smoking
Drinking

For Breast Surgery Patients

For information purposes only — you will receive more options and recommendations during your consultation.

Desired Placement
Desired Implant Type
Desired Incision
Have you had a Mammogram? (patients over 40)

Photos we Require

At NipTuck Holidays, we understand the importance of maintaining your privacy and appreciate your trust. Just like any other personal medical information we need to collect, your private photos remain confidential and are handled with the utmost respect and care.

  • If possible, have someone else take your photos.
  • Make sure your photos are clear and in focus.
  • Take your photos in good, even lighting.
  • Stand against a plain white wall or neutral background.
  • Take photos in a standing position.
  • Stand naturally.
  • Remove clothing and undergarments from the area being assessed.
  • Follow the example images for the correct positions and angles.

Please provide clear photos similar to the examples below to info@niptuckholidays.com

Example: Breast Surgery
Breast Surgery
Example: Facelift
Facelift
Example: Tummy Tuck
Tummy Tuck
Example: Thigh Lift
Thigh Lift
Example: Weight Loss Surgery
Weight Loss Surgery
Example: Cosmetic Gynaecology
Cosmetic Gynaecology

Acknowledgement

Your answers

I hereby confirm that the questions contained herein have been accurately answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health and will incur additional costs to my treatment. It is my responsibility to inform NipTuck Holidays and/or my treating surgeon and hospital of any change in my medical status. I also authorise the medical staff to perform the necessary pre-operative services I may need.

Typing your name counts as the signature.

In facilitating medical tourism services, we collect sensitive personal and health information (including medical histories, diagnostic files, and treatment requirements). To coordinate your care, we disclose this information to third-party medical providers, hospitals, clinics, and surgeons located outside of Australia. Destinations where recipient health providers are located include, but are not limited to: Thailand, Turkey, South Korea, Vietnam, Indonesia (Bali), and Mexico.