Medical Questionnaire "*" indicates required fields Doctor of your interest?*Select a DoctorDr. CamposDr. CabreraDr. IlichDr. MorenoAny DoctorWhat type of procedure are you interested in?* Eye lid/Blepharoplasty Buccal fat removal Chin liposuction Otoplasty Rhinoplasty Face lift Neck lift Breast augmentation with implants Breast augmentation with fat transfer Breast lift Tummy tuck Circular Tummy tuck Tummy tuck & fleur de lis Liposuction Fat transfer to buttocks (BBL) Brachioplasty (Arm lift) Thigh lift (inner thigh lift) Torsoplasty (Back lift) Mastectomy JPlasma Bodytite Facetite Morpheus 8 When do you want to have surgery?* MM slash DD slash YYYY Are you available for last minute surgery?*Yes/NoYesNoHow did you hear about Lotus Med Group?*Select an optionSocial MediaSaw you on googleWord of MouthOtherPersonal InformationFull name* First Last Phone number*Email address* Date of birth* MM slash DD slash YYYY Sex*Select your sexFemaleMaleWeight (lbs)*Height (ft' in")*What city are you contacting us from?*Instagram UserMedical QuestionsDo you smoke or have you smoked in the past?*Yes/NoYesNoHow many cigarettes per day?*How long have you been smoking?*Do you have any illness that requires ongoing treatment?*Do you currently take any medications, supplements or vitamins?*Have you had any surgeries in the past?*Have you had any complications in surgery or anesthesia?*Are you pregnant?*Yes/NoYesNoAre you planning on having children in the future?*Yes/NoYesNoHave you been pregnant before?*Yes/NoYesNoHow many children do you have?*How many of your pregnancies have resulted in live births?*How many were vaginal deliveries?*How many were cesarean deliveries?*Have you had spontaneous abortions?*Yes/NoYesNoHave you had any contraceptive or hormonal treatments in the last 2 years?*Breast Augmentation QuestionsWhat is your current bra size?*What has been your largest bra size?*What is your desired bra size?*Have you ever had a breast ultrasound or mammogram done? (if yes, please specify)*Bariatric QuestionsHave you had bariatric surgery before?*Yes/NoYesNoPlease specify*When did you get your bariatric procedure done?*Was your procedure done in Tijuana?*Yes/NoYesNoWhat was your highest weight before surgery? (lb)*How long have you been at your current weight?*Please attach pictures below as requested in the different angles. Click on the image to zoomUpload 5 face pictures* Drop files here or Select files Max. file size: 32 MB. Upload 5 pictures as indicated above Click on the image to zoom Upload 5 body pictures* Drop files here or Select files Max. file size: 32 MB. Upload 5 pictures as indicated aboveagreement* Check this box if you understand that by clicking “Submit” you agree to share this information with Lotus Med Group team. * PhoneThis field is for validation purposes and should be left unchanged.
