Plastic Surgery Evaluation Formoldd

Conversational Form (#5)

Let Dr. José Mora’s precision meet your desire design your transformation from anywhere in the world.

Share the story your mirror longs to tell and receive a vision of your transformation, crafted with the artistry of Dr. José Mora in the Dominican Republic.

Email (We’ll send you your personalized proposal along with exclusive tips for your surgical journey)

Whatsapp Number (Our concierge team will reach out to you via WhatsApp to guide you every step of the way.)

Name (We want to speak to you with the respect you truly deserve.)

Current country of residence

Age (Every stage of life has its own beauty — we enhance it safely.)

Gender

Female

Male

Other

If your selection was other, please specify the procedure you wish to undergo

Have you had any cosmetic surgery before? This information helps us safeguard your health and plan with precision.

Yes

Not

If you answered yes to the previous question, could you let us know which procedure you had and when? (Your body has already begun a transformation. Knowing which procedure you had and when allows us to offer continuity, safety, and harmony.)

When would you like to have your surgery? We’ll check availability and guide you with suggested dates.

Within the next 30 days

In 1–3 months

In 4–6 months

I’m not sure yet

What is your approximate height? (This information helps us assess your Body Mass Index (BMI) and create a safe, personalized plan.)

What is your approximate weight? (This information helps us assess your Body Mass Index (BMI) and create a safe, personalized plan.)

Blood Type (Every transformation deserves impeccable clinical support. Sharing your blood type is a key step toward your well-being.)

Do you take birth control?

Yes

Not

Are you pregnant?

Yes

Not

How many pregnancies you've had

Have your births been natural or cesarean sections? Indicate how many?

Physical Activity

Mild

Moderate

Very Active

Would you like us to arrange accommodation, transportation, and support for your medical trip?

Yes, I want a full package

I only need the surgery

I’m not sure yet

Is there anything else we should know about you or your expectations? (This space is all yours. Share what you feel, what you dream of, or any detail that matters to you and your experience.)

Personal Medical History

Beauty begins within. Share any medical details we should consider to design a procedure that’s as safe as it is transformative.

Are you allergic to any food?

Yes

Not

Yes? Indicate which one (If you have any food allergies, please let us know here. Every detail matters when it comes to your safety and well-being.)

Are you allergic to anesthesia?

Yes

Not

Are you allergic to any medications?

Yes

Not

If your answer is positive, indicate the medication (Your body deserves complete care. If there are any medications we should avoid during your process, please let us know here.)

Do you have a family history of any illness or health condition?

Yes

Not

If your answer is Positive, please indicate:

Are you or a family member a carrier or suffering from FALCEMIA?

Yes

Not

Have you had COVID?

Yes

Not

Do you take any medications or supplements regularly? (for blood pressure, antidepressants, protein, weight loss supplements, vitamins)

Yes

Not

If you take any medications, please indicate which one

Are you undergoing any medical treatment?

Yes

Not

Indicate it

Do You smoke? Or did you smoke before? Including hooka or e-cigarettes

How many cigarettes do you consume per day?

Do you consume coffee, alcohol, or aspirin?

Yes

Not

How many do you consume per day?

Suffered From Or Is A Carrier Of AIDS

Yes

Not

Suffers Or Suffered From Hepatitis B or C

Yes

Not

Are you under treatment? Provide the name of the medicine

Pathologic Personal History:

Knowing your medical history allows us to make safer decisions focused on your well-being. If you have any pre-existing conditions, this is the place to share them.

If you suffer from any other condition that is not listed, please indicate it

Do you want to write a comment?

Upload your photos with full confidentiality; they’re the foundation for a result that feels authentic, precise, unmistakably you.

Each body is a unique canvas. By sharing your image, we can study your proportions in detail and offer you a proposal that honors your essence and elevates your reflection.

For photos, depending on the procedure you want, place yourself on a preferably white background in a place with good lighting. You should send the photos without clothes to get a valuation and quote as close to reality as possible. One standing in front, the other sitting.
Lateral standing, another sitting. The last one from back to full body.

Front Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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Rigth Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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Left Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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Aditional Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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Aditional Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

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Aditional Picture Image Upload: Accepted file types: jpg, png, max. File size: 20 MB.

Choose File