Zoho Plastic - MedicalMex

Treatment

Email

Zoho ID

Gender

Height

Age

Inches

Date of Birth

Current Weight

Your Lowest Adulthood Weight

Your Current Clothing Size

Your Highest Adulthood Weight

Have you been diagnosed with any medical condition or ilness?

please list the name of the medical condition and year of diagnosis *

Are you taking medication?

please list the name and dosage *

Do you have any allergies?

list the type of allergy *

Have you undergone any surgical procedure?

list name and year of surgical procedure *

Number of Pregnancies

Have you donated blood or plasma

how often have you donated blode or plasma *

Have you been infected with COVID-19?

Have you been fully vaccinated for COVID-19?

Have you been diagnosed with any mental or psychiatric conditions?

list the mental condition and year of diagnosis *

Are you handicapped or require specific transportation services?

please specify the type of disability and transportation requirement *

Do you smoke?

specify the amount and frequency *

Do you drink?

How often do you drink

Diagnosed

Have you ever been diagnosed with the following conditions:

HIV

HEP B

HEP C

STDs

Venereal Diseases *

HIV HTML

Patients who are HIV, HEP B, OR HEP C positive are not eligible for surgery. Patients with uncontrolled high blood pressure or Diabetes must stabilize their BP and glucose levels to be eligible for surgery.

Current Breast Size

What breast size are you interested in

What was your highest breast size ever including pregnancy and/or weight gain?

Female - Diagram

Privacy Protection LawSafeguarding our patient’s personal medical information is our priority and one of our main commitments.

The purpose of forwarding your pictures is to complete your medical evaluation for our Plastic Surgeon, your Surgeon needs to corroborate with both pictures and medical information if you are eligible for the requested surgery.

Your pictures are not shared nor distributed and are solely requested to complete your medical evaluation.

We set in place numerous internal policies, protocols and specialized technology with the purpose of protecting and keeping medical information private and secure, including compliance with the Health Insurance Portability and Accountability Act HIPAA and Mexico’s different sanitary privacy policies.

Please forward at your earlieast convenience pictures as shown in the image (front, right profile, left profile, and back)

Male - Diagram

Privacy Protection LawSafeguarding our patient’s personal medical information is our priority and one of our main commitments.

The purpose of forwarding your pictures is to complete your medical evaluation for our Plastic Surgeon, your Surgeon needs to corroborate with both pictures and medical information if you are eligible for the requested surgery.

Your pictures are not shared nor distributed and are solely requested to complete your medical evaluation.

We set in place numerous internal policies, protocols and specialized technology with the purpose of protecting and keeping medical information private and secure, including compliance with the Health Insurance Portability and Accountability Act HIPAA and Mexico’s different sanitary privacy policies.

Please forward at your earlieast convenience pictures as shown in the image (front, right profile, left profile, and back)

Picture Upload

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