Patient Medical Form

    Select treatment*
    DentalWeight LossPlastic / CosmeticHair TransplantOrthopedicOther(s)

    SURGERY INFORMATION

    Previous COSMETIC surgeries?
    YESNO

    Other surgeries?
    YESNO

    TRAVEL & FLIGHT INFORMATION IF KNOWN

    Hotel reservation:
    YESNO

    Beach Villa Promotion:
    YESNO

    PATIENT MEDICAL INFORMATION

    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

    Patient's Coordinator
    FrankAleClaudiaFabiolaTonyTaniaJoeMarcela

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