Plastic Surgery Evaluation Form

Dr José Mora Plastic Surgery Evaluation Form

Dr. José Mora Plastic Surgery - Evaluation Form

Please answer each of the questions on the feedback form carefully.

Contact Information

First Name

Last Name

Phone/Mobile

Personal Data

Birth Date

Country Of Residence

Gender

Female

Male

Other

Weight

Height

Blood Type

Physical activity

Mild

Moderate

Very Active

Exclusive Section For Females

Do you take birth control?

Yes

Indicate the name of the contraceptive used

Are you pregnant?

Yes

How many pregnancies you've had

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

Personal Medical History

Are you allergic to any food?

Yes

Indicate which one

Are you allergic to anesthesia?

Yes

Are you allergic to any medications?

Yes

If your answer is positive, indicate the medication

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

Yes

If your answer is Positive, please indicate:

Have you had COVID?

Yes

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

Yes

If you take any medications, please indicate which one

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

Yes

How many cigarettes do you consume per day?

Suffers Or Suffered From Hepatitis B or C

Yes

Do you consume coffee, alcohol, or aspirin?

Yes

How many do you consume per day?

Suffered From Or Is A Carrier Of AIDS

Yes

Are you under treatment? Provide the name of the medicine

Pathologic Personal History:

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

Plastic Surgery Section

Select the procedures of your preference from the lists below

Do you want to write a comment?

Your photos

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.

Choose File