Patient Medical Form Name* Please leave this field empty. Phone number* Email* Select treatment* DentalWeight LossPlastic / CosmeticHair TransplantOrthopedicOther(s) Specify treatment: City & State* Emergency contact name Emergency contact phone number Share with us all other medical information pertinent to your treatment SURGERY INFORMATION Surgery type: Approximate surgery date: Location: Previous COSMETIC surgeries? YESNO Please list type of surgery and date performed: Notes: Other surgeries? YESNO Please list type of surgery and date performed: TRAVEL & FLIGHT INFORMATION IF KNOWN Arrival date: Arrival time: Airline and flight number: Departure date: Departure time: Hotel reservation: YESNO If yes, name of hotel Beach Villa Promotion: YESNO PATIENT MEDICAL INFORMATION Medications Allergies Other medical information Height Weight Date of birth. Month, day, year. Gender Diabetes YESNO Hypertension YESNO Sleep disorder 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, which illness Patient's Coordinator FrankAleClaudiaFabiolaTonyTaniaJoeMarcela If other, please write name here Additional comments and questions for the doctor I have read and agree to the Privacy Policy Δ