MEDICAL QUESTIONNAIRE

Based upon your medical questionnaire, we will give you a price quote and additional information about the procedures in which you are interested.  We will also include the number of days needed for post-op recovery before returning home.  Please give us basic information regarding your medical history, and please indicate the procedures you wish.  We will promptly reply with prices and more information.

In order to accurately quote a price, photos of the areas to be enhanced may be necessary.  We respect your privacy so we will ask for them only if necessary.  You may, of course, send photos to us at any time.  Please send them as an email attachment to info@medicalgroupofcostarica.com.

Upon receiving this Medical Questionnaire, our doctors will review everything and an estimate will be sent through our patient coordinator.  You may rely on this estimate as being accurate and firm.  Later adjustments to the quote can always be made between you and the doctors during your pre-op examination.

Pre-op consultations are generally the same day of your arrival, if arriving early enough in the day.  Otherwise, you can relax for the evening at the Costa Rica Medical Center Inn and see us the next day. Pre-op consultations are normally in the late afternoon.  Your surgery will usually be performed the next day.

Medical check-ups prior to surgery can be done here at our hospital, or at home.  We have complete facilities to do all required medical tests quickly and at a nominal cost following you pre-op consultation.

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?:

  Abdomen Ears
  Arms Eyelids
  Breast Augmentation Face
  Breast Reduction Neck
  Buttocks Nose
  Chin Thighs


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