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

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