Cosmetic Surgery Patient Form

Cosmetic Surgery Patient Form

Aesthetique MD Vallarta
Hello,

We require a detailed clinical history form, which takes approximately 10 minutes to complete, before proceeding with a consultation.

For online consultations, we require the same comprehensive information that we obtain during an in-person evaluation. This allows us to properly assess whether you are a candidate for surgery and to provide safe, accurate recommendations.

📸 Photos are required.
Please scroll to the bottom of the form first to review the specific photo requirements before completing the questionnaire. This ensures you have everything prepared and can submit all materials at once.

Incomplete submissions — including missing photos — will not be processed or contacted for consultation.

Please allow up to two weeks for a response.

Thank you for your understanding and cooperation.

— Dr. Kerri
When are you wanting/planning to do surgery?
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
MaleFemale
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Religion (required by Mx law)
Marital Status
Occupation
Emergency Contact Name

First NameLast Name
Emergency Phone Number
PATIENTS PAST MEDICAL HISTORY:

****Required for all patients
HypertensionChest pain or palpitationsHeart DiseaseAsthmaCOPD / emphysema / chronic bronchitisTuberculosisSleep ApneaDiabetesThyroid DisordersAdrenal DisordersObesity: BMI > 35Anemia / Bruising /Bleeding DisorderHistory of Clots or DVTAbnormal Bleeding with SurgeryStrokeAnticoagulant/antiplatelet useBreast CancerCancer treatment (chemo, radiation, etc)Arthritis / ArthralgiaHepatitisHernia / Hernia RepairHIVKidney problemsPrevious MRSA InfectionKeloid or hypertrophic scarringConnective tissue disorders that affect wound healingOther Skin IssuesDepression/ Anxiety / Body Dysmorphic DisorderHeadaches / Epilepsy /Seizure DisordersRecent infections (Skin, Systemic, Urinary)AutoimmuneUnexplained Numbness / Muscle WeaknessOther
If you chose other please write below or include anything left out:
FAMILY MEDICAL HISTORY:

****Required for all patients
Please list family medical history family: (Parents, grandparents, siblings)
MEDICATIONS:

***Required for all patients
Are you currently taking any medications, vitamins, or herbal supplements? If yes, please list them below and provide the purpose and dosage.
ALLERGIES:

****Required for all patients
Do you have any allergies? (Please specify if you are allergic to any of the following: medications, antibiotics, bee stings, cow’s milk, lidocaine, adhesives, latex, iodine, shellfish, etc. Be sure to include the type of allergy and the reaction you experience.)
SOCIAL AND NON-PATHOLOGIC HISTORY:

****Required for all patients
What is your blood type and Rh factor?: (If not known you will need your blood type tested before surgery)
NeverOccasionallyDaily
NeverOccasionallyDaily
NeverOccasionallyDaily
NeverOccasionallyDaily
Sedentary: Little to no exercise, often associated with desk jobs or prolonged sittingLightly Active: Simple daily tasks like walking short distances, light houseworkModerately Active: Regular exercise, such as brisk walking, cycling, or swimming for 30 minutes most daysVigorously Active: Intense physical activity, like running, competitive sports, or heavy manual labor
PAST COSMETIC SURGERIES OR AESTHETICS TREATMENTS:

***Please include Lasers, Morpheus, etc
Please list your aesthetic treatments and or Surgeries: (Date, procedure type, and reason)
GYNECOLOGIC HISTORY:

****Required for all females
When was your first time as an adolescent you started your menstrual period?

MonthDayYear
Date
How many times have you been pregnant?
How many children do you have?
How many C-sections have you had?
How many vaginal births have you had?
Last menstrual period (FUM):

MonthDayYear
Date
YesNo
YesNo
YesNo
Gynecologic surgery: (Date and surgery type)
REASON FOR CONSULTATION:

****More than one choice can be chosen
Breast Augmentation (I do not have implants)Breast Augmentation (I have implants)Breast LiftBreast Lift and AugmentationMommy Makeover (Tummy Tuck, Breast, Lipo, BBL)Abdominoplasty - Tummy tuckFaceliftMini Facelift /Temporal lift /Pony tail liftBlepharoplasty Upper (Eyelid Surgery)Blepharoplasty (Lower Eyelid Surgery)Blepharoplasty (Upper and Lower Eyelid Surgery)Rhinoplasty (nose surgery)Eyebrow liftLip LiftEarring hole repairLiposuction 360Liposuction HDLiposuction NeckBichectomy (Buccal Fat Removal)Brazilian Butt Lift (BBL)Gluteal (bottom) augmentation with implantsArm Lift (Brachioplasty)Rib RemovalHair GraftPenile implantOther, please explain in the section at the very end
VITAL SIGNS AND WEIGHT ASSESSMENT:

****Required for all patients
Less than 120/80 mm Hg120-129 / less than 80 mm Hg130-139 / 80-89 mm Hg140 or higher / 90 or higher mm Hg
What is your current weight and height
What is your waist size?
If you lost or gained weight in the past 6 months please explain how much and if you used Ozempic, Mounjaro, or any other type of semaglutide´s in the past 6 months and the last time it was used:
YesNo
BREAST SECTION:

*****this part can be skipped if it doesn´t pertain to your type of surgery
YesNo
YesNo
If you are over 40 when was your last mammogram?:

MonthDayYear
Date
What is your bust size? (example, 34B)
Please explain the implant and or bust size you are interested in having if you have or do not have implants: (Leave blank if you do not know)
Left BreastRight Breast
YesNo
If you have implant´s please write the date of your last breast augmentation surgery (please approximate if not known).

MonthDayYear
Date
MentorAllerganOther
If you currently have implants, are they:
Subglandular (under the gland and above the muscle)Subfascial (above the muscle and under the fascia)Under the muscleI do not remember
If you currently have implants, how many CC´s, the profile as Mentor (Moderate, Moderate Plus, High, Ultra high, or Boost) or Allergan (SRX, SCX, SRS) of your Right implant?
If you currently have implants, how many CC´s, the profile as Mentor (Moderate, Moderate Plus, High, Ultra high, or Boost), or Allergan (SRX, SCX, SRS) of your Left implant?
YesNo
Do you feel you may have implant rupture?
YesNo
Do you feel you may have capsular contracture?
Left implant serial number:
Right implant brand serial number:
ADDITONAL INFORMATION FOR ALL SURGERIES:
Please write any other type of important information you would like the surgeon to know that was not asked:
FACE PROCEDURES
Front: Face (no smile)

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Front: Face (neck bent back and looking to celing)

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Front: Face (neck bent foward looking to the floor)

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Right side 45 degree angle: Face

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Left side 45 degree angle: Face

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Right side: Face (looking straight)

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Left full side: Face (looking straight)

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Left right full side: Face (neck bent looking down)

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Left full side: Face (neck bent looking down)

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BREAST PROCEDURES
Front: Breast (arms relaxed to side of body)

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Front: Breast (arms above head looking up)

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Right side 45 degree angle: Breast (arms down to the side)

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Left side 45 degree angle: Breast (arms down to the side)

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Left side 45 degree angle: Breast (arms above head looking up)

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Left side 45 degree angle: Breast (arms above head looking up)

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Right full side: Breast (arms down to the side)

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Left full side: Breast (arms down to the side)

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FULL BODY PROCEDURES
Front: Full body (neck to feet with arms relaxed to the side)

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Right side 45 degree angle: Full body (neck to feet with arms horizontally in front)

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Left side 45 degree angle: Full body (neck to feet with arms horizontally in front)

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Left Full Side: Full body (neck to feet with arms horizontally in front)

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Right Full Side: Full body (neck to feet with arms horizontally in front)

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Back: Full body (neck to feet with arms relaxed to the side)

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ADDITIONAL OR OTHER TYPES OF PHOTOS
Please upload additional or other types of photos not mentioned that may be needed for consultation
TikTokInstagramFacebookGoogle SearchReferred by a friendOther
If you were referred by a friend please write their first and last name:
VirtualIn person
If virtual please write time zone, 3 dates, and times your are available: (Saturday, Sunday, and evenings are ok)
Please upload your Diagnostics and Lab work required after your consultation for your surgery
Should be Empty:

Cosmetic Surgery Patient Form

PATIENTS PAST MEDICAL HISTORY:

FAMILY MEDICAL HISTORY:

MEDICATIONS:

ALLERGIES:

SOCIAL AND NON-PATHOLOGIC HISTORY:

PAST COSMETIC SURGERIES OR AESTHETICS TREATMENTS:

GYNECOLOGIC HISTORY:

REASON FOR CONSULTATION:

VITAL SIGNS AND WEIGHT ASSESSMENT:

BREAST SECTION:

ADDITONAL INFORMATION FOR ALL SURGERIES:

FACE PROCEDURES

BREAST PROCEDURES

FULL BODY PROCEDURES

ADDITIONAL OR OTHER TYPES OF PHOTOS