surgery patient form – Leplaztique Dr. Luis Plazas

HOME
ABOUT US
RESULTS
PROCEDURES
FORM
CONTACT

SURGERY PACIENT FORM

First Name *

Last Name *

Email Address *

Confirm Email Address *

City *

State/Province *

Country *

Gender *

Age (click to calculate)

🚨 ATTENTION: If your BMI is greater than 35.0, you must lose weight first before we can provide a quote. If your BMI is below 35.0, you may continue with the process to receive your quote. 🚨

BMI (click to calculate)

Body *Please attach (6) pictures (Front, Side, Back) :

Drag and Drop (or) Choose Files

How do you know about us: *

Instagram User *

Form Section

List the procedures you want to have done

procedure0 / 50

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

DiabetesHight CholesterolThalassemiaHight Blood PressureAnginaChest PainsixHeart FailureCancerLupusAsthmaSleep Apnea

ArthritisGERD/HeartburnHIVSickle Cell TraitSickle cell anemiaHepB / HepCThrombosisTrombophiliaJoint painBack painUlcersLiver Disease/Hepatitis

Frequent diarrheaBladder incontinenceCrohn’s disease or colitisOther(s)

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

About Us

Innovation in Aesthetic and Reconstructive Plastic Surgery. You are one step away from achieving the figure you have always wanted to have, we have excellent financing plans

Call us

+57 300 357 3728

+57 320 4623189

Write a message

contact@leplaztique.com

Our address

Cali - Colombia

CLINICA CORPUS Y ROSTRUM
Calle 3Oeste # 34- 96 Consultorio 201