Formulario Cirugía Plástica ´´Todo incluido´´

Patient form

This form should only be completed if you want plastic surgery with our coordination in the Dominican Republic.
Below you will find a series of questions related to your health and your plastic surgery. It is extremely important that you answer them honestly, as they could be crucial when planning and executing your process.

This information will help us take all the necessary precautions and safeguards for your health, in addition to helping to provide you with appropriate care. If you are not sure about any question posed, or do not understand its meaning or importance, or how it relates to your health condition, please discuss it with us by writing to us at +1(829)-743-9778.

Thank you very much for choosing us!

- 809 Plastic Surgery.
NAME AND LAST NAME*

NameLast name
CELLPHONE NUMBER*
800-000-0000
EMAIL*
example@example.com
ADDRESS*

Street

Address line 2

CityState / Province

Postal code
GENDER*

FemaleMale
DATE OF BIRTH*

DayMonthYear
Fecha
AGE*
WEIGHT IN POUNDS*
HEIGHT IN FEET AND INCHES*
Have you had any surgery previously?*

YesNo
If yes, which surgeries have you had?
Enter the approximate dates of the interventions
Which procedure(s) do you want to perform?*

Breast augmentationBreast reductionBreast liftAbdomen LipoLipoesculptureLipo 360Back LipoLipo HDBrazilian Button Lift (BBL)Tummy TuckBrachioplastyLabiaplastyImplants extractionBiopolymers extractionFaceliftBlefaroplastyRinoplastyOtro

PERSONAL MEDICAL HISTORY: (check only the option that applies)*

	Yes	No	Not sure
Headaches, seizures, dizziness, paralysis
Anemia, blood disorders or clotting problems
Ulcer, gastritis, cirrhosis, colitis, hemorrhoids
Asthma, tonsillitis. emphysema, laryngeal or bronchi affection
Diabetes
Thyroid diseases, alterations in blood fats or uric acids
Surgeries, traumas, (accidents)
Cancer, tumors, radiotherapy or chemotherapy
Hypertension, heart attacks, angina, murmurs, arrhythmias, coronary heart disease
Infectious: Have you had or suspect you have Hepatitis, tuberculosis, AIDS or HIV (+), syphilis or any serious infectious disease?
Skin infections
Kidney diseases
Biopolymers
Falcemia
Pregnancies
Allergies

Substance intake: (check only the option that applies)*

	Yes	No	Occasionally
Hookah
Marihuana
Alcohol
Contraceptive method
Weight loss pills

Do you take medications daily?*
Our all-inclusive package includes the following. Which amenities do you NOT need?*

Airport round trip transportationTransportation for post-surgical visitsTransportation to the clinic5 post-operative massagesHotelRecovery House (12 days)Medication kitI would like the complete package
¿Qué tipo de experiencia le gustaría?*

Experiencia normalExperiencia V.I.P
Extras you want to add to your experience

Box of personal hygiene items (US$130)Skin Care Box ($145)Essential Wound Healing Box ($80)Breast Kit Box (US$140)Lipo+Abdominoplasty Box with +30 supplies (US$330)BBL box with +30 supplies (US$370)Colonial Zone/City Tour before surgery (US$25-US$80)Extra days at the recovery house (amount to be defined)Extra post-surgical massage package (5-10 massages) (amount to be defined)Hyperbaric chamber sessions (US$100 per session)Companion (amount to be defined)
Which specialist do you want your surgery with?*

Dr. Orlando Vargas AlmonteDra. Lourdes RodriguezDr. Luis CabralDra. Marta VargasDr. Luis Lima VargasDr. Pablo GrullónI haven't decided yet
Date you would like your surgery*

MonthDayYear
Do you need financing?

YesNo
ANY OBSERVATIONS AT THE MOMENT ABOUT YOUR HEALTH and/or THE ALL INCLUSIVE PACKAGE
Upload images of the area(s) you want to treat. The photos must be as follows: Without showing the entire face (in the case of facial surgeries, focus on the area); without any distractions (earrings, clothing, hair). A photo from the front, a photo from the right side, a photo from the left side, a photo in 3/4 and another photo from the back (in case of body procedures).

Cancelof
Declaration: The patient registers and declares that all information indicated or omitted in this medical record is his or her exclusive responsibility, expressly releasing our company from any liability, both civil and criminal, that may arise as a result of erroneous, incomplete, or false information. or omitted.

The patient provides this information only for the purposes of his procedure; this information may not be disclosed to third parties without his prior consent, except for legal requirements.

The patient who signs this form expressly declares that he knows and accepts the above to his full and total satisfaction.
Sign the document*

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HOW DID YOU KNOW US?*

Google SearchRecommendationSocial networksConferenceWeb pageCongress
Promotion Code
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Patient form