plastic surgery recovery 011+(506) 2252-3530
U.S. (786) 228-9148 (305) 395-7207

   

PERSONAL INFORMATION

 
Name:
Email Address:
Country:
   
plastic surgery costa rica

PROCEDURE
Please choose procedure(s) you wish to undergo:

   
 


   
Please refer me to a doctor
 
 
surgery costa rica

MEDICAL INFORMATION

 
Age:
Sex: Male   Female
Weight: lbs.
Height: ft. in.
   
Have you ever suffered from one
or some of the following diseases?

Heart disease
Asthma
High Blood Pressure
Epilepsy
Coagulation Disorder
Ulcer
Diabetes
Allergies

Types of Allergies:

 

Do you smoke? Yes   No
Do you drink alcohol? Yes   No
Are you taking any medications?

Yes   No

Types of medication:

   
Have you had surgeries in
the past?

Yes   No

Please list type of surgery & dates:

   
Comments:
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