Pre-Consultation Form
We require you to complete all sections of the Pre-Consultation Form and provide good-quality pictures. This will give us the information we need to offer you an appropriate medical opinion and an exact quote tailored to your needs.
NOTE: All information received will be treated as strictly confidential.
The easiest way to answer all the questions is to COPY and PASTE.
COPY all the questions and then PASTE them into the email you will send to us.
Please send the form below 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:
-
-
-
-
2. Attach your Photos:
Photos are essential for our surgical team to establish a clear and precise preliminary medical diagnosis.
Required photos:
For Body Surgery (body photographs of Front, Back and Profile - face photos are not required for body surgeries).
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 undergo this type of surgery?
2) What are your reasons for wanting this surgery?
3) Have you previously consulted with a plastic surgeon? If so, when and under what circumstances.
4) Why did you choose Top Plastic Surgeons Mexico to perform your surgery?
ARRIVAL DATE
1) When are you planning to arrive in Mexico? (Please specify the month or day, so we can provide you with available dates)
2) How many days can you stay in Mexico? (Depending on the procedure(s) you want to undergo, you may need to stay in Mexico between 7 to 15 days to ensure proper recovery).
3) The Scala Magna Hotel Suites & Villas 4**** is the hotel included in your package.
Would you like to upgrade to a different hotel for an additional cost?
4) Excursions and Tourism in Mexico. If you're interested in excursions or tourist activities, please let us know which places you'd like to visit.
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