Health Questionnaire & Quote Request Form

1
NamePlease enter your name as it appears on your ID
First Name
Last Name
2
Mobile Number (Must have WhatsApp)
Please enter a valid phone number.
3
Email
example@example.com
4
Instagram
5
Which type of procedures / services are you seeking?
Plastic Surgery
Bariatric Surgery
Cosmetic Dentistry
Recovery House
101 with Cherry Martinez
Private Accomodations
6
Who referred you? Please list the person or place that referred you
7
Desired Arrival Date* This field is required.
Date
Month
Day
Year
8
Gender
Female
Male
9
Date of Birth
10
Age
11
Height * This field is required.
12
Weight in LBS* This field is required.
13
Number of Pregnancies
14
Date of Last Pregnancy
15
Known Allergies?
16
Known Medical Conditions
17
List Previous Surgeries & Date
18
Are you currently taking medications?
YESNO
19
If so, which?
20
Do You SmokeCigarettes, Hookah, Marijuana, Vape
Yes
No
21
Do You Drink Alcohol
YESNO
22
Do You Use Recreational Drugs?
YESNO
23
Do You Suffer From Hyper/Hypotension?
YESNO
24
Do You Suffer From Sickle Cell Disease / Trait Carrier ?
YESNO
25
Do You Suffer From Díabetes ?
YESNO
26
Do You Suffer From Thyroid Disease ?
YESNO
27
Do You Suffer From Asthma?
YESNO
28
Do You Suffer From Anemia?
YESNO
29
Do You Suffer with Mental Health?Depression, Anxiety, BPD, ADHD, Methadone Mgmt
YESNO
30
Do You Have a Cancer History?
YESNO
31
Are you HIV / AIDS Positive?
YESNO
32
Have you had COVID-19?
Yes
No
33
Have you been vaccinated with the COVID vaccine?
Yes
No
34
If you have been vaccinated, what was the date of your last dose?
35
Desired Procedures* This field is required.
Lipo 360 & BBL
Lipo Tummytuck & BBL
Mommy make over
Breast Only
Thigh lift
Arm lift
Back lift
Chin lipo
Blepharoplasty (eyelid surgery)
Fillers / Botox
Smile Design
Teeth Whitening
VSG / Bariatric
36
Do you have a specific surgeon in mind?* This field is required.
Dr García Lopez
Dr José Hungria
Dra Miurbys Contreras
Dra Nellyveth Guilamo
Dra Ruth Arias
Dr Yoiner Cedeno
Dra Israel Manon
Dr Jairo Ulerio
Dra Yvelise Bello
Dr Christian Porras
Dra Glori Mercedes
Dr Jose Miguel Diaz
Open to Suggestions
Dr. Gian Contreras
37
Which of the following services are you interested in* This field is required.Select all that interest you
Surgery
Recovery House
101 Consulting with Cherry
Massage Therapy
Surgery Supplies
Stage 2 Faja
Nursing Companion
Overnight Nurse
Private Nursing
38
Upload Your Photos
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
39
Upload Your Photos
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
40
Upload Your Photos
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
41
Upload Your Photos
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
42
Preferred Room Type* This field is required.
Private
Double
Triple
No Sure Yet
43
Estimated Length of Stay* This field is required.
7 Days
10 Days
14 Days
Drs Recommendation
Not Sure
44
Need Massages with Your Recovery?* This field is required.
Yes, include in my quote
No, I will arrange my own
Not Sure Yet
45
Should We Include Transportation in Your Quote?* This field is required.
Yes, please!
No, Ill arrange my own.
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