Interstate and Overseas Patient Enquiry Form 
Date:
Name:
Address:
Email:
Australian Contact Number (if available):
Are you happy for us to send any written material you request to the address provided?
Yes No
Do you have accommodation in Melbourne for your recovery?
Yes No
What will your duration of stay be? - minimum 14 days required
Are you interested in receiving information about our private apartment, Tilley's Place?

Yes No
What will your duration of stay be? - minimum 14 days required
If you decided to have surgery in Melbourne will you be travelling with a partner or friend?
Yes No
Your Age:
Your Past Surgical History:
Your Past Medical History:
Do you have, or have you ever had, any of the following
Allergies:
Yes No
Bleeding Problems, Phlebitis, Blood Clots:
Yes No
Diabetes:
Yes No
High Blood Pressure:
Yes No
Heart Trouble:
Yes No
Rheumatic Fever:
Yes No
Blood Disease:
Yes No
Asthma:
Yes No
Hepatitis:
Yes No
HIV:
Yes No
Please list your current medications and or medical concerns:
Please list your long term medication or herbal remedies:
Please explain what surgery you are interested in and what it is about your face that you would like corrected:
Please attach two or more current photos of yourself, in profile and full face (.gif or .jpeg extension image files only):

Photo 1:
Photo 2:
Photo 3:
Photo 4:
 
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