FORM - Leplaztique Dr. Luis Plazas

First Name *

Last Name *

Email Address *

Confirm Email Address *

Phone Number *

City *

State/Province *

Country *

Gender *

Body *Please attach (3) pictures (Front, Side, Back) :

How do you know about us: *

Instagram User *

Form Section

List the procedures you want to have done

procedure0 / 50

Age *

Weight (lbs) *

Height (inches)

Approximate date you would like your surgery

Do you have any allergies? *

If so, provide the name (s) *

Smoke? *

Cigarrete/Day *

Drink liquor?

Use recreational drugs *

Illness

Please indicate if you have any of the following

Other Illness (please specify) *

Do you use any steroid? *

If so, provide the name *

Have you ever need psychiatric treatment? *

If so, provide the name *

Have you had any pregnancy? *

If so, how many children do you have? *

Date of last pregnancy or abortion *

Normal birth or by cesarean section? *

Previous surgeries *

Name of previous surgeries *(Please explain with detail, specify where and when)

Any complications during or after the surgeries?

Describe complications during or after the surgeries? *

Do you have any kind of substances inject in your Body? *

If so, Specify Body Part *

Which medication you consume?

Certify *I certify that the information provided on this application is accurate, true and correct.

Concent *I read and accept the term and condition from LEPLAZTIQUE - Dr. Luis Eduardo Plazas

PACIENT FORM

Form Section

Illness

Please indicate if you have any of the following