Plastic Surgery Request

Name*

Last Name*

Phone*

Email*

Procedure of Interest*

Sex*

Age*

City

Do you take any medications/drugs?*

Yes No

Specify Medications*

Previous Bariatric Surgery*

Yes No

Which one?*

Date of surgery*

Do you smoke cigarettes?*

Yes No

Do you drink alcohol?*

Yes No

Use recreational drugs?*

Yes No

Diabetes*

Yes No

Any other illnesses*

Yes No

Specify conditions*

Do you use any type of birth control?*

Yes No

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?*

Photos: No need to send photos of patient completely naked, wearing bikini, underwear or gym clothes are also accepted

Front*

Back*

Left Side*

Right Side*

Select your preferred measurement system

Maximum weight (lb)*

Current weight (lb)*

Height (feet)*

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.