Patient Medical Form – TEST PICS

Name*

Please leave this field empty.

Phone number*

Email*

Select treatment*
DentalWeight LossPlastic / CosmeticHair TransplantOrthopedicOther(s)

Specify treatment:

State & City*

Emergency Contact

Emergency Contact

All other patient information pertinent to your treatment

SURGERY INFORMATION

Surgery type:

Approximate surgery date:

Location:

Price Quoted:

TRAVEL INFORMATION & FLIGHT INFORMATION IF KNOWN

Arrival date:

Time:

Flight:

Departure date:

Time:

Hotel reservation:
YESNO

Beach Villa Promotion:
YESNO

Additional comments:

PATIENT MEDICAL AND GENERAL INFORMATION

Medications:

Allergies:

Other medical information

Height

Weight

Age

Gender

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
If yes

PHOTOS

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

Patient's Coordinator:
FrankAleClaudiaFabiolaIrvingOther

If Other:

Message

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