First Name *

Last Name *

Email *

Phone *

Country *

Select your country

Age *

Under 18

18–21

22–30

31-45

Over 45

Preferred Language *

English

中文 (Mandarin)

Preferred Contact Channel *

Whatsapp

WeChat

Email

WeChat ID

Whatsapp

Current Height (cm) *

Current Weight (kg) *

Desired Height Increase *

3–5 cm

6–8 cm

9–10 cm

More than 10 cm

Unsure

Nicotine Use *

No

Occasionally

Daily

Recently stopped

Vaping / nicotine pouches

Relevant Medical Conditions *

Diabetes

Vascular Disease

Neurological Disease

Autoimmune / Inflammatory Disease

Bone Disease / Osteoporosis

Thrombosis / PE

Severe Organ Disease

Active Infection

None

Other

Previous surgery, injury or joint problems *

No

Previous surgery

Fracture / injury

Deformity / malalignment

Hip / knee / ankle pain

Unsure

What best describes your motivation? *

I have carefully considered this procedure

I feel limited by my height and want a structured evaluation

I believe surgery will solve personal or emotional problems

I feel pressure from others or social media

Unsure

How would you describe your understanding of the process? *

Full understanding, I have researched this thoroughly

Partly understand, I need more information

I expected a simpler procedure

I want the fastest possible result

Have you researched the approximate investment? *

Yes

Roughly

No

Are you prepared for the rehabilitation and follow-up process? *

Fully prepared for up to 12 months

Willing but need more details

Unsure

No, expect quick recovery

Expected Cost Range *

Under €50,000

€50,000–€100,000

€100,000–€150,000

Over €150,000

Are you worried about the appearance of some part of your body? *

No

Yes

Do these concerns preoccupy you?

No, not at all

Yes, somewhat

Yes, a lot

Has this concern caused distress, upset or anxiety?

No, not at all

Mildly

Moderately

Severely

Extremely severe

Has your concern interfered with social life?

Not at all

Mildly

Moderately

Severely

Extremely Severely

Has your concern interfered with work or role fulfilment?

No, not at all

Mildly

Moderately

Severely

Extremely severe

Have you avoided things because of appearance concerns?

No

Yes Mildly

Yes Moderately

Yes Severely

Yes Extremely severe

Have you ever felt housebound due to appearance concerns?

No

Yes

Have you previously undergone cosmetic procedures? *

No

Yes, one

Yes, multiple

Yes, more than five

Your responses are kept strictly confidential and used solely for the purpose of assessing suitability for further consultation. This form does not constitute medical advice.

I have read and agree to the Privacy Policy. I consent to my health data being processed for the purpose of this medical assessment.

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