Costa Rica Center of Plastic Surgery

Dr. Luis Pacheco, M.D.



Medical Questionnaire



Please complete the following and submit to us:
First Name: *
Last name: *
Email: *
Sex: Male Female
Age: years
Weight:
Height:


What type of cosmetic surgery interests you?:
  Abdomen Ears
  Arms Eyelids
  Breast Augmentation Face
  Breast Reduction Neck
  Buttocks Nose
  Chin Thighs


Other:
Please list any previous surgeries with dates:
How is your general health?: Excellent Good Fair Poor
Do you have any particular health problems? If yes, please explain:
Any allergies? ( please specify ):
Any negative experience with anesthesia?. If so, please explain:
Medicines you take at present:
Do you use tobacco?
Please list below any specific comments or questions you may have:
Please give us a preferred date and a secondary date, if possible, for your procedure:
Preferred date:
Secondary date:
Thank you. We will promptly replay with answers to any questions you may have. A general overview of your requested surgery, a price quote, and availability of your requested dates will also be sent.
The * denotes mandatory field