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.