Medical Questionnaire

Please complete the following and submit to us:

First Name:

Last name:

Email:

Sex:

Male Female

Age:

years

Weight:

Height:

What type of cosmetic surgery interests you?:

Other:

Please list any previous surgeries with dates:

How is your general health?: Excellent Good Fair Poor

Do you have any particular health problems? If yes, please explain:

Any allergies? ( please specify ):

Any negative experience with anesthesia?. If so, please explain:

Medicines you take at present:

Do you use tobacco?

Please list below any specific comments or questions you may have:

Please give us a preferred date and a secondary date, if possible, for your procedure:

Preferred date:

Secondary date:

Thank you. We will promptly replay with answers to any questions you may have. A general overview of your requested surgery, a price quote, and availability of your requested dates will also be sent.

The * denotes mandatory field

Guadalajara Plastic Surgery Center

Medical Questionnaire