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Application for Plastic Surgery

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Have you received any treatment with us before?* YesNo

Birth Date*

Do you take any medications/drugs?* YesNo

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

Penicillin* YesNo

Sulfa Drugs* YesNo

Iodine* YesNo

Tape* YesNo

Latex* YesNo

Aspirin* YesNo

High lipid levels* YesNo

Previous Bariatric Surgery*

Date of surgery*

Have you ever had a problem with an anesthetic?* YesNo

Do you smoke cigarettes?* YesNo

Do you drink alcohol?* YesNo

Use recreational drugs?* YesNo

Are you easy fatigued?* YesNo

Do you have shortness of breath?* YesNo

Do you have asthma?* YesNo

Stroke* YesNo

Diabetes* YesNo

Coronary Artery Disease* YesNo

Liver disease* YesNo

Lung disease* YesNo

Renal disease* YesNo

Thyroid disease* YesNo

Hypertension* YesNo

Any other illnesses* YesNo

Date of last menstrual period*

Do you use any type of birth control?* YesNo

Birth Control*

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

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

Have you had any previous surgery?* YesNo

Previous Surgery

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

Do you exercise?* YesNo

Exercise

When are you planning on having surgery?*

Photographs: Completely Naked so doctors can have a clear view of surgical areas for evaluation.

Front*

Back*

Left side*

Right side*

REFERENCES

  • For your evaluation this info must be submitted. The surgeons will evaluate your case based on a overall individualized cased. Surgical plan can be changed upon consult face to face evaluation.

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CONTACT US!

At Plástica Tijuana, we are here to help you. We take the time to explain our procedures and answer your questions. We want you to feel comfortable and confident before deciding to undergo cosmetic surgery. You can expect a warm, friendly attitude from our highly professional staff. Our staff is highly trained in advanced medical procedures and observes strict safety protocols, and is fluent in both English and Spanish.




    New City Medical Plaza P.° del Centenario 9580, Zona Urbana Rio Tijuana, 22010 Tijuana, B. C. Floor: 19- Suite:1901

    New City Medical Plaza P.° del Centenario 9580, Zona Urbana Rio Tijuana, 22010 Tijuana, B. C. Floor: 19- Suite:1901

    US CALLS & TEXT (619) 955 7224

    US ONLY CALLS (619) 240 8571

    MX CALLS ONLY (664) 650 7898

    contact@plasticatijuana.com

    All rights for CERVANTES & ARAGON PLASTIC SURGERY GROUP© 2023