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Medical Questionnaire

 

To give you accurate information about the procedure you have in mind, we need to know just a little about your medical history It is not necessary to send us photos as we respect your privacy issues, but we will always welcome a photo of your area of interest if you wish to forward one. The email address is crivera@vibrolipocr.com Upon receiving your Medical Questionnaire, Dr. Rivera will determine the scope of your requested surgery, and send an estimate through his patient coordinator.  You may rely on this estimate as being accurate and factual. You can, of course, make later adjustments by adding or changing procedures either in advance or during your pre-op examination with the doctor. Your initial consultation will be either on the same day you arrive if you arrive early enough in the day, or the day following your arrival, as you prefer. Your procedure will usually be done the day following your pre-op. A medical checkup is necessary and you may either have it done at home, or here at our hospital. We have complete facilities to do all required medical tests quickly and at a nominal cost.

 

Please describe the surgery you wish to have:

Do you have any specific concerns
or questions about the procedure?

First name:

Last name:

 

Sex: F      M

 

Email address:

Are you taking any kind
of medication?

Yes      No

If so, please list:

Have you had any surgeries in the past?
If so, when? (please give some detail):

Have you ever suffered one or more of the following illnesses?

Heart diseases

Epilepsy

Diabetes

Asthma

High blood pressure

Coagulation disorders

Ulcer / Gastritis

Do you smoke?

Yes      No

Please check surgery availability, your preferred dates:

1st choice

2nd choice

 

The following is only for breast procedures
and abdominal walls surgery:

 

a) How many pregnancies have you had? How long ago?:

 

b) Did you breast feed your children?

Yes      No

 

Thank you. We will reply promptly with prices and availability.

 

 

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