Bali Cosmetic & Dermatology Treatment Assessment Form

Step 1 of 8

Name(Required)

First Last

Date of Birth(Required)

Country of Residence(Required)

Mobile Number (including country code)(Required)

Email Address(Required)

Preferred Contact Method(Required)

Phone

Facebook Messenger

Section 8 – Final Declaration

Is there anything else you would like the treatment team to know?

The information you provide in this assessment form will be used solely for the purpose of enabling participating healthcare providers to review your enquiry and offer preliminary, non‑binding feedback regarding potential treatment options. You may choose to upload supporting materials such as scans, reports, treatment plans, quotations, or photographs to facilitate this review.

Submission of this form does not create any obligation to pursue treatment, nor does it establish a patient–provider relationship.

All personal and health information supplied will be stored securely using Google services and may be used only for the following purposes:

Evaluating your enquiry and circumstances
Facilitating discussions regarding potential treatment options
Sharing your information with healthcare providers only where you have requested or provided consent
Coordinating introductions or referrals where appropriate

Your information will not be sold, transferred, or disclosed to third parties for commercial purposes. You retain the right to request access to, correction of, or deletion of your information at any time, subject to applicable legal and record‑keeping requirements.

Consent

By submitting this form, you acknowledge and consent to:

The collection, electronic storage, and use of your personal and health information for the purposes described in the Privacy Notice above.
The sharing of your information with healthcare providers only where you have expressly requested or authorised such disclosure.
The understanding that this assessment form is intended exclusively for preliminary information‑gathering and does not constitute medical advice, diagnosis, treatment, or a substitute for consultation with a qualified healthcare professional.

Important: If you experience severe pain, significant swelling, uncontrolled bleeding, difficulty breathing or swallowing, signs of infection, vision changes, or any form of trauma following a cosmetic, dermatology, aesthetic, surgical, or related procedure, you should seek urgent medical care immediately.

Signature

Full Name Confirmation(Required)

Date(Required)

Bali Cosmetic & Dermatology Treatment Assessment Form

Section 2 – Treatments of Interest

Section 3 – Skin & Treatment History

Section 4 – Medical History

Section 5 – Travel Planning

Section 6 – Decision Making

Section 7 – Uploads

Section 8 – Final Declaration

Consent