First contact

Brief assessment

Tell us what care you need. This short form helps prepare your assessment; it does not confirm an appointment.

Asked to complete your full medical history? Start here.

Full name *Age (years) *SexSurgery or treatment of interest *

Weight, height and BMI

Weight unitWeight *Height unit

Height (cm) *

BMI is calculated automatically from your weight and height. It is a screening measure; it does not determine surgical eligibility on its own.

Medical conditions *

Previous surgeries (optional)Medications and allergies (optional)Phone *Email *

When you submit, your answers and contact details are saved in the clinic’s CRM so the team can follow up. This is a brief assessment, not your full medical history. Do not use this form for emergencies.