Online Suitability Assessment

Suitability assessment
Am I suitable?

Please complete our online suitability assessment to determine if you are an appropriate candidate for a cosmetic surgical procedure.

Advantages of the online suitability assessment:

  • No need to travel long distances for consultation
  • Completely free
  • You will be assessed directly by a surgeon
  • Quick and hassle-free

The Online suitability assessment is a service offered to patients who may have difficulty travelling to us because of the long distances involved. It is designed to provide potential patients with general feedback and information in order to better decide whether to seek care and treatment at Centre for Surgery. The online suitability assessment consists of two parts: Online suitability questionnaire and an Online suitability consultation via Skype.

Please take time to fill out all questions on the form below carefully and completely. Please take special care in ensuring that photos you submit are of good quality and are made in accordance with the photo quality/size guidelines. Our surgeons will review the submissions and determine whether you are a suitable candidate for treatment. If you are a suitable candidate for treatment based on the information provided, you will be scheduled for an online Skype consultation directly with a surgeon. All suitable prospective patients will be followed up with a face-to face consultation.

Terms and Conditions

The online suitability questionnaire and online suitability consultation is a service offered to patients for maximum convenience. It is designed to provide potential patients with general feedback and information in order to better decide whether to seek care at Centre for Surgery. The response we provide is based solely on our interpretation of the limited data provided and should not be viewed as comprehensive, definitive or final.

The Online Preliminary Consultation form is not intended to replace or serve as a substitute for a medical examination and consultation with a surgeon at Centre for Surgery

Use of the Online Suitability Assessment (online questionnaire and online consultation) does not constitute the establishment of a doctor-patient relationship between the surgeon and the service user.

Any information sent via the preliminary online suitability questionnaire forms is secure and treated in the strictest confidence. However, we cannot guarantee the security of information transmitted electronically. If you have concerns regarding this possible breach of privacy, please contact us by alternative means.

Photo Guidelines

Please follow these instructions:

Camera

Use a good quality digital camera. Do not use cameras on mobile phones. Use the camera’s normal or zoom lens (not wide angle as this may cause distortion).

Image

Image should be sharp and in-focus, showing close-up views. Expression should be natural and relaxed, without smiling. Lighting should be even and without strong shadows. Use a plain background

Perspective

Keep the camera level with the area photographed. (Do not photograph upwards or downwards).

Photo 1: Straight-on front view

Photo 2 and 3: 45-degree side-view, right and left

Photo 4 and 5: 90-degree profile-view, right and left

Size

Images larger than 2 MB may not transmit. Cropping out extraneous detail or downsizing the image should prevent this problem.

Suitability Assessment Form

Title*

First Name*

Last Name*

Email*

Telephone*

Date of birth*

Profession*

Address Line 1*

Address Line 2

Town/City*

Country*

Postcode*

Best Time to Call*

Weight

Height

Smoking

Do you have any known allergies

If yes please specify

Do you take Aspirin, lbuprofen, Nurofen, Fish Oil, Flax Oil, Omega Oil or Vitamin E

Medications taken

Alternative medicines (incl. herbal and homeopathic medicines)

Do you have any general health problems or conditions?

If yes please specify

Have you had any previous surgery?

If yes, please list procedures, approximate dates and outcomes

Do you usually heal well after suffering minor wounds?

If no, please describe

Do you usually have prolonged bleeding after suffering
minor wounds?

What type of surgery are you considering?

Please describe as specifically as possible the nature of your concern and desire for surgery

Please describe your expectations from surgery

Do you have any particular concerns regarding the surgery?

If yes, please specify

Have you already seen another doctor regarding this surgery?

If yes, please note their recommendations

Do you have any special requirements we should know about?

If yes, please explain

Is there any other information you wish to share with us now?

If yes, please explain

Do you understand and accept in full the Terms and
Conditions of Use for the Online Suitability Assessment form?

Type your full name to attest that the enclosed
information is accurate and complete

Attaching Photos

You may attach up to 5 photos from your computer. Please review our guidelines and the photo quality/size requirements before
attaching your files.

Attach image. Required to attach minimum one photo

Note: If for any reason you are unable to attach images to the form, you may email them separately along with a brief message
clearly identifying yourself and the images.

Submitting your form

Copy of this form will be emailed to email provided in this form.

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