Patient Medical Form – TEST PICS

    Select treatment*
    DentalWeight LossPlastic / CosmeticHair TransplantOrthopedicOther(s)

    SURGERY INFORMATION

    TRAVEL INFORMATION & FLIGHT INFORMATION IF KNOWN

    Hotel reservation:
    YESNO

    Beach Villa Promotion:
    YESNO

    PATIENT MEDICAL AND GENERAL INFORMATION

    Diabetes: YESNO
    Hypertension: YESNO
    Sleep disorder: YESNO
    Bone problems: YESNO
    Obesity related problems: YESNO
    Respiratory: YESNO
    Compulsive eating: YESNO
    Reflux: YESNO
    Hernia: YESNO
    Digestive: YESNO
    Are you pregnant? YESNO
    Do you smoke? YESNO
    Are you currently ill? YESNO

    PHOTOS

    Do you have a picture that might work for the doctor to see?

    Patient's Coordinator:
    FrankAleClaudiaFabiolaIrvingOther


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