Medical Questionnaire

Please complete the following and submit to us:

* First Name:

* Last Name:

* Email:

Sex:

Male Female

Age: years

Weight:

Height

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

Tags: The Costa Rica Center Of Plastic Surgery, costa rica, plastic surgery, Dr. Luis Pacheco, M.D. Board Certified plastic surgeon. Here is a medical questionnaire, pre-surgery checklist, dr. luis pacheco, Botox, eyelift, forehead lift, Facial Wrinkle Reduction, Fat Injections, Injectable Fillers, Restylane, Laser Resurfacing, Face, Spider Vein Removal, the Plastic Surgery Center of Costa Rica, Dr. Luis pacheco, plastic surgeon, medical questionnaire, health. Dr. Pacheco is one of the top rated plastic surgeons in San Jose, Costa Rica and has the lowest prices possible.

Costa Rica Center of Plastic Surgery

Medical Questionnaire