Plastic Surgery Request – GALAZ Plastic Surgery

Have you received any treatment with us before?*

Yes No

Name*

Last Name*

Sex*

Age*

Birth Date

Phone*

Email*

Address

Zip Code

City

State

Country*

Services*

Procedure of Interest*

Do you take any medications/drugs?*

Yes No

Specify Medications*

Why are you taking them?*

How long have you been taking them?*

Do you take, or have you take in the past Blood-thinners?*

Yes No

Penicillin*

Yes No

Sulfa Drugs*

Yes No

Iodine*

Yes No

Tape*

Yes No

Latex*

Yes No

Aspirin*

Yes No

High lipid levels*

Yes No

Previous Bariatric Surgery*

Yes No

Which one?*

What was your age?*

What year was it performed?*

Date of surgery*

Any complication?*

Have you ever had a problem with an anesthetic?*

Yes No

Do you smoke cigarettes?*

Yes No

Do you drink alcohol?*

Yes No

Use recreational drugs?*

Yes No

Are you easy fatigued?*

Yes No

Do you have shortness of breath?*

Yes No

Do you have asthma?*

Yes No

Stroke*

Yes No

Diabetes*

Yes No

Coronary Artery Disease*

Yes No

Liver disease*

Yes No

Lung disease*

Yes No

Renal disease*

Yes No

Thyroid disease*

Yes No

Hypertension*

Yes No

Any other illnesses*

Yes No

Specify conditions*

Date of last menstrual period*

Do you use any type of birth control?*

Yes No

Type*

How long have you used this birth control?*

Are you presently, or have you ever taken hormones?*

Yes No

Are you presently, or is there a possibility of you being pregnant?*

Yes No

Have you had any previous surgery?*

Yes No

What surgery?*

What was your age?*

What year was it performed?*

Any complications?*

Do you use or B-PAP while your sleep?*

Yes No

Do you exercise?*

Yes No

Type*

How long?*

How often?*

Hours per day*

Religion*

Preferred language*

How did you hear about us?*

Which other?*

When are you planning to have surgery?*

Photos: Completely naked so that doctors can have a clear vision of the surgical areas for evaluation.

Front*

Back*

Left Side*

Right Side*

Select your preferred measurement system

Maximum weight (lb)*

Current weight (lb)*

Height (feet)*

BMI*

REFERENCES

• To your evaluation, you must submit this information. The surgeons will evaluate your case according to an individualized analysis. The surgical plan may be modified after an in-person evaluation.