International Patient Medical Record

We are excited to start working on the best version of yourself

Thank you for choosing us to build together the image you’ve always dreamed

Step 1

Calculate your Body Mass Index and save the result.

Step 2

Please fill out the form, let’s start working on the best version of yourself.

The purpose of this questionnaire is to find out the best way to help you reach your expected results.
This form is protected by Doctor–patient confidentiality, so please answer as truthfully and accurately as possible.

Name *

Gender *

Phone *

Email Address *

Country

Social media username

Date of Birth *

Month

Day

Year

Blood type

IMC Results *

Weight *

Height *

Do you have kids? *

If yes, how many?

Do you take any prescribed medication? *

if the answer is yes, please specify.

Do you have any health problems? *

if the answer is yes, please specify.

Have you had any surgery before? *

if the answer is yes, please specify.

Do you suffer from any kind of allergies? *

if the answer is yes, please specify.

Do you smoke? *

if the answer is yes, please specify.

How often do you smoke?

Do you drink alcohol? *

How often do you drink alcohol?

What is the approximate date for your procedure

1

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cualquier duda o pregunta no dudes en contactarnos!!