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Authentication Information

Email Address *

Password *

Confirm Password *

Profile Information

Full Name *

Preferred Name

Phone Number *

Pronouns

Sex Assigned at Birth *

Date of Birth *

Gender

Preferred Language

Preferred Contact Method *

Height (cm) *

Weight (kg) *

Preferred Destination

Preferred Surgery Timeframe

How did you hear about us?

Transgender Social Transition (Optional)

If applicable, please specify when you started your social transition

Month

Year

Address

Procedures Considering *

Goals & Expectations

Emergency Contact (Required)

Contact Name *

Contact Phone *

Relationship *

Local GP / Doctor Contact

Please provide the contact details of your local general practitioner (GP) or doctor.

GP / Doctor Name

GP / Doctor Email

GP / Doctor Phone

Medical Conditions

Please indicate Yes or No for each of the following conditions.

	Yes	No
Diabetes or blood sugar problems
Heart problems
Blood pressure problems
Blood disorders
HIV or AIDS
Neurologic problems
Previous history of Deep Vein Thrombosis (DVT) or Pulmonary Embolism

	Yes	No
Thyroid problems
Lung problems
Kidney or Liver problems
Previous/current history of cancer
Nervous Breakdowns / Depression
Anesthesia problems

If you have answered YES to any of the above, please specify:

Have you had or do you have any medical conditions not mentioned above?

Yes

No

If yes, please specify:

For Women

Do you take birth control pills, hormone replacement medication, or wear a hormone patch?

Yes

No

For Women Having Breast Surgery or Tummy Tuck

Have you undergone any surgical means of birth control (e.g. Tubal Ligation)?

Yes

No

Are you pregnant now?

Yes

No

Are you planning any more pregnancies?

Yes

No

How many children have you had?

How old is your youngest child? (Month & Year)

Have you ever breastfed?

Yes

No

When did you last breastfeed? (Month & Year)

Do your breasts still have milk at this time?
NOTE: Lactation may also be induced by other factors such as hormone intake. Please test by squeezing breasts.

Yes

No

Medical History

Have you been hospitalized or received medical care in the past 12 months?

Yes

No

If yes, when?

If yes, what was the reason?

Have you had any surgery before?

Yes

No

If yes, when?

If yes, what kind?

Do you have fillers, implants or any metal objects in your body?

Yes

No

If yes, please specify what & when it was inserted/injected:

Do you have difficulty with healing or scarring?

Yes

No

Do you have any allergies to food, drugs, etc?

Yes

No

If yes, please specify:

List all medications you currently take (include dosage):

List all vitamins or food/nutritional supplements you currently take:

Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?

Yes

No

If yes, when was your last dose?

Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin?

Yes

No

If yes, when was your last dose?

Do you smoke?

Yes

No

If yes, how much do you smoke?

If yes, when did you last smoke?

Do you drink alcohol?

Yes

No

If yes, how much do you drink?

(Please tick) I hereby certify that all the information above are true and correct.

Upload Documents

Identity Document (Passport/ID Card)

Upload a clear copy of your passport or national ID card (PDF, JPG, PNG - Max 5MB)

Medical Records (Optional)

Upload relevant medical records, lab results, or doctor's reports (Multiple files allowed - Max 5MB each)

Reference Photos (Optional)

Upload photos for consultation reference (Multiple files allowed - Max 5MB each)

Insurance Documents (Optional)

Upload insurance card or policy documents if applicable (PDF, JPG, PNG - Max 5MB)

I agree to the Terms and Conditions

By checking this box, I acknowledge that I have read, understood, and agree to CRM Sally's Terms and Conditions, Privacy Policy, and Medical Tourism Service Agreement. I understand that:

Medical procedures involve inherent risks and potential complications
CRM Sally acts as a facilitator connecting patients with qualified medical professionals and facilities
All medical decisions should be made in consultation with qualified healthcare providers
I am responsible for following all pre and post-operative care instructions
Travel and accommodation arrangements are subject to availability and third-party terms
Payment terms and cancellation policies apply as outlined in the service agreement
My personal and medical information will be handled according to our Privacy Policy

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