IF YOU THINK YOU ARE QUALIFIED TO A SURGERY PLEASE FILL OUR MEDICAL FORM FIRST!
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COSMETIC DENTISTRY
COSMETIC DENTISTRY
IMPLANTS
BRIDGES
CROWNS
TEETH WHITENING
DENTAL CARE
ENDODONTIC
PERIODONTIC
MEDICAL SPA
BOTOX
FILLERS
HYPERBARIC CHAMBER
ANTI-AGING TREATMENT
SPA TREATMENTS
FACIALS
MASSAGES
INFRA THERAPY CAPSULE
HAIR REMOVAL
AESTHETIC SURGERY
BREAST
MOMMY MAKEOVER
TUMMY TUCK
LIPOSUCTION
BRAZILIAN BUTT LIFT
AFTER WEIGHT LOSS
BEFORE AND AFTER
BARIATRIC SURGERY
GASTRIC SLEEVE
GASTRIC BYPASS
REVISION SURGERY
SINGLE INCISION
MINI BYPASS
DUODENAL SWITCH
SADIS SURGERY
MEDICAL FORM
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Medical
Form
Send us the form with your information so we can evaluate your case.
The information received will be treated with full confidentiality.
Name
*
First
Last
Age
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Email
*
Phone
*
Emergency contact name & phone number
*
In what surgery are you interested?
*
Gastric Sleeve
Single Incision
Gastric Bypass
Mini Gastric Bypass
Lap Band
Duodenal Switch
SADI Surgery
Revision Surgery
Gastric Ballon
Mommy Makeover
Liposuction
Tummy Tuck
Body Lift (After Weight Loss)
Breast (Augmentation, Reduction or Lift)
Brazilian Butt Lift
Another Surgery / Treatment
Your Measurement
Weight
*
Height
*
Your Weight Goal
For female patients only
Abortions
Birth Control Pills
List any past surgeries you've had:
Heart Diseases
Yes
No
Hypertension
Yes
No
Myocardial Infarct
Yes
No
Diabetes
Yes
No
Asthma
Yes
No
Lung or Breathing problems
Yes
No
Cancer
Yes
No
List all the medications you take every day for a chronic disease
Have you been diagnosed with:
Hepatitis
AIDS/HIV
Kidney Disease
Bleeding Disorder
Colitis (cronh)
Cancer
Multiple Sclerosis
Others
Drugs Allergic
Do you take this drugs?
Heparin
Cumarin
Warfarin
Aspirin
Tobacco use:
Yes
No
If yes, How much?
Alcohol
Yes
No
Everyday
Message
*
IF YOU THINK YOU ARE QUALIFIED TO A SURGERY PLEASE FILL OUR MEDICAL FORM FIRST!
COSMETIC DENTISTRY
COSMETIC DENTISTRY
IMPLANTS
BRIDGES
CROWNS
TEETH WHITENING
DENTAL CARE
ENDODONTIC
PERIODONTIC
MEDICAL SPA
BOTOX
FILLERS
HYPERBARIC CHAMBER
ANTI-AGING TREATMENT
SPA TREATMENTS
FACIALS
MASSAGES
INFRA THERAPY CAPSULE
HAIR REMOVAL
AESTHETIC SURGERY
BREAST
MOMMY MAKEOVER
TUMMY TUCK
LIPOSUCTION
BRAZILIAN BUTT LIFT
AFTER WEIGHT LOSS
BEFORE AND AFTER
BARIATRIC SURGERY
GASTRIC SLEEVE
GASTRIC BYPASS
REVISION SURGERY
SINGLE INCISION
MINI BYPASS
DUODENAL SWITCH
SADIS SURGERY
MEDICAL FORM
ABOUT US
UNITED MEDICAL CREDIT
MEDICAL TEAM
TESTIMONIALS
BLOG
COORDINATOR IN YOUR AREA
CONTACT
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