Dr. Jose Medina | Medical Questionnaire

Please complete the following and submit to us:

* First Name:

* Last Name:

* Email:

Sex:

Male Female

Age: years

Weight:

Height

What type of cosmetic surgery interests you?:

Other

Please list any previous surgeries with dates

How is your general health?: Excellent Good Fair Poor

Do you have any particular health problems? If yes, please explain:

Any allergies? ( please specify ):

Any negative experience with anesthesia?. If so, please explain:

Medicines you take at present

Do you use tobacco?

Please list below any specific comments or questions you may have:

Please give us a preferred date and a secondary date, if possible, for your procedure:

Preferred date:

Secondary date:

Thank you. We will promptly replay with answers to any questions you may have. A general overview of your requested surgery, a price quote, and availability of your requested dates will also be sent.

The * denotes mandatory field