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


    When are you planning on having surgery?*

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

    • 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.


    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.