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Breast Surgery
Breast Implants Breast Augmentation Breast Reduction Breast Lift Breast Reconstruction Tram Flap Surgery Breast Cancer Male Breast Reduction
Body Contouring
Weight Loss Liposculpture Liposuction Abdominoplasty Tummy Tuck Gastric Bypass Arm Lift Lower Body Lift Buttock Implants Buttock Lift Thigh Lift
Facial Rejuvenation
Rhinoplasty Blepharoplasty Face Lift Brow Lift Chin Implants Cheek Implants Lip Augmentation
Non-Surgical Treatment
Botox® Restylane Collagen Injection Dermabrasion Fat Injection Radiesse

Medical Questionnaire Form Plastic Surgery in Costa Rica In order to evaluate your general physical condition please fill in this online Medical Questionnaire Form by answering each question carefully. For your free consultation, you may also email us recent photographs from the front and both sides of the area where you wish to have Plastic Surgery performed. Please e-mail photos in .jpg format to: info@costaricanewlook.com or by regular mail to INTERLINK 963 P.O. Box 02-5635 Miami FL 33102 The doctor needs this information to make sure that you will benefit from the best medical treatment. All fields are requiered.
General Information
First Name:
Last Name:
Email:
City:
State:
Country:	*
Phone:
Sex:	Female Male
Date of Birth:
Marrital Status:	Married Single
Weight:	lbs.
Height:	ft. in.
Occupation:
How to contact you:
Online Consultation
Anticipated Date of Surgery:
What type of cosmetic surgical procedure do you wish to have?	Breast Surgery Breast Implants Breast Augmentation Breast Reduction Breast Lift Breast Reconstruction Tram Flap Surgery Breast Cancer Male Breast Reduction Body Contouring Weight Loss Liposculpture Abdominoplasty Gastric Bypass Arm Lift Lower Body Lift Buttock Implants Buttock Lift Thigh Lift Facial Rejuvenation Rhinoplasty Blepharoplasty Face Lift Brow Lift Chin Implants Cheek Implants Lip Augmentation Non-Surgical Treatment Botulinum Toxin Type A - Botox® Restylane Collagen Injection Dermabrasion Fat Injection Radiesse Other Procedures please specify
Reason why you wish to have surgery?
How is your health?	Excelent Good Fair
Have you had plastic surgery before?	Yes No
If yes, what procedure did you have done?
Where you satisfied with the results?	Yes No
Were there any surgical complications? Please explain?
General Allergies (Please Specify):
Allergies to Medications (Please Specify):
Are you allergic to tape?	Yes No
Any bad reaction with anaesthesia?	Yes No
If yes, please explain:
What medications do you currently take?
How many aspirins (or aspirin products) do you take daily?
Do you take vitamins? (Please Specify):
Do you smoke?	Yes No
How many cigarettes daily?
Alcohol intake:
Have you seen a psychiatrist in the past five years? If so, please explain::
Other Comments:

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All information submitted is considered strictly confidential and will never be sold, traded, or given to any third party for any reason whatsoever. Your contact information will be kept strictly confidential.

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1 (239) 331-5601

Medical Questionnaire FormPlastic Surgery in Costa Rica

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Plastic Surgery - Cosmetic Surgery - Reconstructive Surgery - Costa Rica Health

Medical Questionnaire Form
Plastic Surgery in Costa Rica