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Form Leplaztique
Please read and complete the information
Name
*
Last Name
*
Mobile
*
Email
*
City / Country
*
Gender
*
Female
Male
Transgender
Please attach (3) pictures (Front, Side, Back) :
Drop files here or
How do you know about us:
Instagram
Facebook
Realself
Referred
Magazines
Website
Google
Instagram User
List the procedures you want to have done
Weight (lbs)
*
Height (inches)
*
Age
*
Approximate date you would like your surgery
Mar 20
Apr 20
May 20
Jun 20
Jul 20
Aug 20
Sep 20
Oct 20
Nov 20
Dic 20
Do you have any allergies?
*
Yes
No
Smoke
*
Yes
No
Sometimes
Cigarrete/Day
Drink liquor
*
Yes
No
Use recreational drugs
Yes
No
Illness
Please indicate if you have any of the following
Diabetes
*
Yes
No
Hight Cholesterol
*
Yes
No
Thalassemia
*
Yes
No
Hight Blood Pressure
*
Yes
No
Angina
*
Yes
No
Chest Pain
*
Yes
No
Heart Attack
*
Yes
No
Heart Failure
*
Yes
No
Cancer
*
Yes
No
Lupus
*
Yes
No
Asthma
*
Yes
No
Sleep Apnea
*
Yes
No
Arthritis
*
Yes
No
GERD/Heartburn
*
Yes
No
Liver Disease/Hepatitis
*
Yes
No
Liver Disease/Hepatitis
*
Yes
No
Crohn's Disease/Colitis
*
Yes
No
HIV
*
Yes
No
Sickle Cell Trait
*
Yes
No
Sickle cell anemia
*
Yes
No
HepB / HepC
*
Yes
No
Back pain
*
Yes
No
Thrombosis
*
Yes
No
Trombophilia
*
Yes
No
Other Illness (please specify)
Do you use any steroid?
*
Yes
No
If so, provide the name
Have you ever need psychiatric treatment?
*
Yes
No
If so, Specify
Have you had any pregnancy?
*
Yes
No
If so, how many children do you have?
Normal birth or by cesarean section?
Normal birth
By cesarean section
Date of last pregnancy or abortion
Previous surgeries
(Please explain with detail, specify where and when)
Any complications during or after the surgeries?
Do you have any kind of substances inject in your Body?
*
Yes
No
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
Name
This field is for validation purposes and should be left unchanged.
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