DERMATOLOGY & AESTHETICS ENQUIRY FORM

ℹ Please complete all sections marked * before submission. This form enables our dermatology and aesthetics team to prepare your telemedicine consultation. All information is treated as strictly confidential

1. PERSONAL DETAILS

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Email Address(Required)

Mobile Number(Required)

Country of residence

Australian State / City

2. REFERRAL SOURCE

How did you find us?(Required)

If other, please specify

Referring person / Organization

3. TREATMENT YOU ARE SEEKING

ℹ Tick all that apply. If you are unsure, leave blank and describe your concerns in the comment box — our team will assess at your telemedicine consultation.

3. TREATMENT YOU ARE SEEKING(Required)

Additional comments about your treatment needs:

Do you have recent skin photos, previous treatment notes or product information to share?(Required)

Yes - I will email them

Not Sure

4. BUDGET (OPTIONAL)

Your budget is completely optional to disclose. Sharing it helps our team prepare information that aligns with your goals and financial expectations.

Would like to share my approximate budget(Required)

Yes

Budget Range (AUD)(Required)

Currency Preference

5. TRAVEL & STAY

Preferred dates — from(Required)

Preferred dates — to(Required)

Expected length of stay?(Required)

Flying from (airport)(Required)

Assistance in Bali — please tick all that apply:(Required)

Airport transfer on arrival — to your hotel

Hotel to hospital transfers — during appointment or treatment days

Airport transfer on departure — hotel to Ngurah Rai

Accommodation recommendations — near hospital or clinic

Accommodation in Bali (if booked)(Required)

6. HEALTH & MEDICAL

Skin Concern History(Required)

Medical conditions we should be aware of(Required)

Current skincare products(Required)

Current Medications(Required)

Allergies(Required)

Pregnant or breastfeeding?(Required)

History of cold sores?(Required)

History of keloid scarring or pigmentation after treatment?(Required)

Previous adverse cosmetic or skin treatment reaction?(Required)

If yes, please describe below

Level of treatment anxiety(Required)

Additional health information:

7. CONSENT & DECLARATION

Signature(Required)

Print Name

Date

YOUR PATIENT JOURNEY — INQUIRY TO AFTERCARE

What happens after you submit this form

1	Inquiry received Your form is reviewed within 1 business day and the next step for dermatology or aesthetics review is confirmed.
2	Telemedicine consultation A video consultation or preliminary photo review is scheduled. Please have clear photos and current skincare details ready. Preliminary only; in-person assessment is required.
3	Treatment pathway & estimate issued You may receive a proposed pathway, cost estimate in IDR/AUD and appointment timing. Indicative until in-person skin assessment.
4	Booking terms Any deposit, payment or cancellation terms are stated clearly before booking.
5	Arrival & clinic meet and greet Your PIC or clinic team assists with registration and directs you to the treatment area.
6	In-person assessment & consent Your treating provider reviews your skin, confirms suitability, explains risks and obtains consent.
7	Treatment & payment Treatment is performed by the treating provider. Payment follows the estimate or appointment confirmation.
8	Aftercare & follow-up You receive aftercare instructions and follow-up contact details for any concerns. WhatsApp aftercare support where included.

InMedika Hospital Bali — Dermatology & Aesthetic Medicine