Form – Dr Hugo Rodríguez

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Note:

PLEASE CHECK BMI TO KNOW IF YOU CAN DO THE SURGERY. BMI MAXIMUM IS 32.

Best regards,

Dr. Hugo Rodríguez

Plastic, aesthetic, laser and reconstructive surgery

Whatsapp: (+57)3202838154

Mail: [email protected]

GENERAL INFORMATION

Full name:

Passport number

Date of birth:

Age:

Gender:

City:

Country:

Cell phone:

E-mail:

How did you know about us?

MEDICAL CONDITIONS

Do you have any of the medical conditions listed below?

Diabetes Kidned Disease HIV/AIDS Hepatitis Stomach Problems Viral illness Respiratory illness Cancer Asthma Sickle Anemia Heart Attacks Epilepsy High Blood Pressure Psychiatric Diagnosis (depression, anxiety, etc) Other

What other?

Do you have allergy?

Yes No

Which allergy?

Unit of measure for weight and height

Weight:

Height:

How many children do you have?

How old are they? (optional)

Do you take medication? (Ex. Prescriptions, Over the counter medications, aspirin, vitamins, herbal supplements).

Have you ever used tobacco products?

Yes No

Do you or have you ever used any drugs?

Yes No

SURGERY

Have you performed surgeries before?

What kind of surgeries have you performed before?

Do you have biopolymers or biogel injetions?

Yes No

When are you looking for your surgery?

What procedures would you like to do?

Tummy tuck Rhinoplasty Breast reduction Breast lift Arm lift Body contouring Liposuction Brazilian Butt Lift (BBL) Gynecomastia Facelift Blepharoplasty Fat transfer Breast augmentation Lip augmentation Thigh lift Arms lipo Inners thigh lipo Chin lipo Buccal fat removal Fibrosis treatment Scar revision Ottoplasty Liposculture 360 Labioplasty

PHOTOS

IS IMPORTANT TAKE COMPLETELY NAKED PHOTOS, WHOLE BODY (WITHOUT EMOJIS) CLEARLY VISIBLE. (NOT IN FRONT OF THE MIRROR) TAKE 4 PICTURES OF FRONT, BOTH SIDES AND BACK.

Ok I understand

Please send your photos. (Max. file size 10 MB)

Data protection

I accept that my data is treated in accordance with the data protection law and the company's privacy policy.