ThePre-Consultation Form

To provide you the best service, we require you fill out all the stages of the Pre-Consultation Form accompanied by good quality pictures, which will provide us the necessary information; and will allow our medical team to evaluate your case and give you an exact and appropriate medical diagnosis, and a quotation tailored to meet your needs.

NOTE: All information received will be treated as strictly confidential.

 

The easiest way to respond all the questions is to do a COPY / PASTE.
COPY all the questions and PASTE them in the mail you will send us.


Please send us this form to:
Contact@TopPlasticSurgeonsMexico.com

 

PERSONAL INFORMATION
Name:
Age:
Phone (Cell phone / Home):
Address:
City:
Country:

 

Your Email:
be sure your mail is correctly written


 

 

INFORMATION CONCERNING TO YOUR SURGERY

1. Describe the Procedure(s) you would like to perform:

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2. Send your Pictures:
To complete the Pre-Consultation form we need you send us your photographs. These pictures are indispensable for our surgical team to be able to establish a clear and accurate preliminary medical diagnosis.

 

Required photos:
For Body Surgery (body photographs of Front, Back and Profile - face photos are not required).

              For Face surgery (Face photographs of Front and Profile – both sides - body photos are not required).
 

 

 

 

 

MOTIVATION LETTER

1) How long have you wanted to have this type of surgery?


2) What are your reasons for having this surgery?

3) Have you previously consulted a plastic surgeon? If so, when and under what circumstances.


4) Why have you chosen Top Plastic Surgeons Mexico to perform your surgeries?



 

ARRIVAL DATE
1) When are you planning to arrive at Mexico (we need to know the month or day your would like to arrive)?


2) How many days can you stay in Mexico (depending on the procedure(s) you would like to perform you will have to stay in Mexico from 7 to 15 days to ensure a good recovery).


3) The hotel included in your package is the:  Scala Magna Hotel Suites & Villas 4****
    Would you prefer an upgrade hotel for an additional cost?


4) Excursions and Tourism in Mexico.

If you wish to make an excursion or tourist activity in Mexico City, please tell us about the places you would like to visit.

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MEDICAL HISTORY FORM

- Size:


- Weight:


- Maximum Weight?

 

- Chest size:

 

- Waist:

 

- Do you smoke?

  If yes, how many cigarettes a day?

 

- Do you drink alcohol?

  If yes, how often?

 

- Are you using any kind of drugs or taking any medications? 

 

- Are you currently undergoing any treatment? 

  If yes, which one?

 

- Do you have any allergies?

  If yes, what are they?

 

- Are you allergic to any medicines?

  If yes, what are they?

 

- Others?

 

- Are you diabetic?

 

- Do you suffer from cholesterol problems?

 

- Do you suffer from high blood pressure?

 

- Do you suffer from anaemia?

 

- Have you gone through depression?

 

- Did you have any viral illnesses?

  If yes, which one?

 

- Have you had any medical surgical procedure(s) before?

  If yes, which ones?

 

- Have you had any cosmetic / plastic surgery ?

  If yes, which ones (part of your body)?


 

Gynecological and obstetrical History (only for women)

- Number of pregnancies?

 

- Number of children?

 

- Number of caesareans?

 

- Would you like to have more children?

  If yes, when?

 

- In Case of Breast Surgery

  What is your cup size?

 

- Have you had mammography?

  If yes, when? What was the result?

 

- Have you ever had breast cancer?

  Is there any family history of breast cancer?

  If yes, which member of the family?

 

 

 

Please send us this form to :
Contact@TopPlasticSurgeonsMexico.com

 

Top PLASTICSURGEONS MEXICO

​Phone 1 (Mexico): (0052) 1 55 63 16 98 95 
Phone 2 (Mexico): (0052) 1 55 68 02 42 72

For a quicker reply, please fill out the
Pre Consultation Form

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