All your information will be used for medical history purposes only.
There is no obligation by filling out this Health Questionnaire. Terms and Conditions only apply upon booking your surgery if you decide to do so.
Full Name *
Phone Number *
Date of Birth *
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Height (Feet) *
Height (Inches) *
Weight (Lbs.) *
Have You Had a Previous Weight Loss Procedure? *
What was your máximum weight before Weight Loss Procedure?*
Have you had any Surgical Procedures? *
Include all Surgical Procedures*
When was the last surgery?*
Did you have any complications? *
What has been your maximum weight?*
How long have you been at your current weight? *
Have you had weight loss surgery before? *
What procedures? *
¿What was your maximum weight before your surgery?*
Have you had any pregnancies? *
How many? *
Have you had Cersareas?*
What Surgery Are You Interested In? *
Desired Surgery Date (Optional)
Referred by (Optional)
Ongoing Medical Conditions
Have you been diagnosed with Hepatitis, diabetes or hypertension? *
Are you taking any Medication? *
Describe which of prescriptions and which are not.*
Do you have any Illnesses? *
Include all Conditions, Diseases, Syndromes or Current Illnesses. *
Drink Alcohol? *
Do you Smoke? *
Do you use any other Nicotine Products? *
Other Nicotine Products? *
Anything related to your medical history that has not been covered? *
Please indicate medical history that has not been covered *
Any questions for your surgeon? *
Please indicate any questions or comments*
To complete the process, we ask you to attach your photos of the areas you want to modify with plastic surgery and they should be sent as follows:
They should be taken without clothing or underwear and from the neck to the knees. Please do not include your face in photographs.
(Example of Image, Finals will be sent in separate file.)
These should be taken from head to shoulders.
Front side profile:
Left side profile:
Left angle profile:
Right side profile:
Right angle profile:
Important note: For a correct assessment by our doctor it is extremely important to follow the aforementioned indications.
Photographs are an essential requirement to continue with your evaluation process.*
Terms and Conditions *
1. All information that you are required to provide with this Health Questionnaire, as well as any other medical information thereafter, is required to be truthful, complete, and accurate. If it is not accurate, the surgeon can cancel your surgery resulting in the loss of security deposit and all money paid for the surgery.
2. It is imperative that the height and weight reported on the Health Questionnaire be accurate. ALL patients are weighed and measured before surgery. If the BMI (Body Mass Index) at the time of surgery does not accurately reflect the height and weight reported on the Health Questionnaire, the surgeon(s) may exercise their right to forego the surgical procedure and any deposit made will be forfeited.
3. If you decide to schedule your surgery, we reserve the right to be able to contact you via phone, email, and/or text. Any previous settings for those communication methods to be disabled will be overridden.
I agree to the Terms and Conditions.
Signature (Gently tap on signature pad prior to signing) *
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