Confidential — for clinical use only

Patient intake & pre-consultation form

Please fill this in before your first consultation. It helps Dr. Khanna assess whether limb lengthening is right for you, and what to discuss. Fields marked * are required. Your information is not shared without your consent.

Reviewed by Dr. Aman Khanna, M.S. Orthopaedics — an orthopaedic surgeon. Limb lengthening is bone surgery, not physiotherapy.

Section 1Personal details Print clearly

As per passport / ID

Gender

DD / MM / YYYY

With country code

Section 2Physical measurements

cm

cm

kg

Gain = target − current—

Typical gain per stage is up to about 6 cm per segment; the realistic target for you is decided at consultation from your X-rays. Gain = target height minus current height.

Procedure interest

Section 3Reason for consultation
Primary reason — tick all that apply

How long have you been considering this?

How did you hear about us?

Section 4Medical history Confidential
Do you have any of the following?

List all, or write NONE

Prior orthopaedic surgery

Smoking status

Alcohol

Section 5Psychological readiness
Impact of your current height on daily life (1 = minimal, 10 = severe)

Currently seeing a psychologist or psychiatrist

Body dysmorphic disorder (BDD)

Social / family support for this decision

Aware that full recovery takes 12–18 months?

An independent psychological evaluation is part of candidacy for every cosmetic case before any surgery is scheduled. This section helps us plan it; it is not a test to pass.

Section 6Financial & travel readiness
All-inclusive budget range

Preferred surgery timeline

Travel & accommodation assistance

A caretaker will accompany you

Section 7Your questions for Dr. Aman Khanna

Have you consulted other surgeons or centres?

Please attach or send by WhatsApp, if you have them

Patient consent & declaration

Privacy: what you type stays on your own device until you choose to send it. Nothing is stored on this website, and there is no server receiving this form. When you press WhatsApp or Email, your own app opens with the message ready for you to check before you send.

I confirm that the information I have given is accurate and complete, and I consent to its use for pre-consultation assessment by Dr. Aman Khanna and his team only. I understand that this form is not a booking and does not commit me to surgery.

Patient signatureDate (DD / MM / YYYY)Place

Send your answers

Both buttons check the required fields first. Then your WhatsApp or email app opens with a plain-text summary of your answers.

Send via WhatsApp Email instead

Prefer paper? Use “Download / print this form” and choose “Save as PDF” in the print window. Please also send any X-rays by WhatsApp +91 89808 22922.