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hello@diviarchitectc.com

1234 Divi St. #1000
San Francisco, CA 94220

(255) 352-6258

M-F | 8:30am – 5:30pm

Name *

Last Name *

Age *

Gender *

Preferred language

How did you find out about Novus Medical Tourism? *

Email *

Phone Number *

Additional Phone Number

City and state of residence *

Weight (lbs. or kg.) *

Height (ft. or mts.) *

Body mass

Blood Group (Blood Type)

Maximum weight you have ever had *

Select *

If true, approximately: How much have you gained in the last 3 months?

Do you have any physical impediment? If so, please mention it

Medication and Supplements

We strive to provide quality care and services to our patients. During virtual consultations, we request that patients provide us with all relevant medical and supplementary information. This may include any medical history, current medical treatments, medications being used, allergies, and general health information. Additionally, we request any supplementary information that may be relevant to the consultation. This way, we can ensure that our patients receive the best possible care.

*(including hormonal contraceptives and hormone therapies)

Relevant medical information (medications in use, brand, dose and reason for use) If this is not the case, you can leave it blank.

Illnesses you have suffered or are currently experiencing.* Please select the boxes that apply.Cardiovascular diseaseDiabetes type 1Type 2 diabetesAsthmaCholesterolThyroidArthritisHeart attacksAnemiaKidney DiseasesOsteoporosis or OsteopeniaObesityLupusPolycystic ovary syndromeBleeding or Clotting ProblemsProblems with AnesthesiaAllergiesBlood clotsHigh pressureMultiple sclerosisDiagnosed DepressionCancer

Other Personal Conditions

Do you have allergies? (If so, please mention which ones)

Have you had any Bariatric Surgery, Gastric Sleeve, Gastric Bypass, Mini Gastric Bypass? If so, mention them and the their respective dates

Have you had Injections for the Buttocks? If so, mention the date of the last

Have you had any other surgery in the past? Please mention which ones with their approximate dates (Month and Year)

Surgical complications that you have had in your past surgeries?(Please describe)

Gyneco-ostetric history

*If you are a man, please skip this section.

Have you had a pregnancy? If so, mention the date of your last pregnancy

How many deliveries?

How many C-sections?

How many abortions?

Menarche

Menstrual cycle

Contraceptive Method (including hormonal contraceptives and hormonal therapies)

Personal Habits

Please make sure you do not omit any drugs or substances. Rest assured that you will not be judged for it and having this information will allow our surgical team to act correctly in the event of a complication within the operating room.

Do you smoke? *

Approximately: What is your alcohol consumption per week?

Any other substance for recreational use that you consume? If so, please mention which one

Approximate date of interest for your surgery *

Facial SurgeryBlepharoplastyNeck stretchFace liftChin implantEars / OptoplastyRhinoplastyBichectomyLipo-Double Chin

Breast SurgeryBreast SurgeryBreast AugmentationImplant ReplacementBreast LiftBreast ReductionGynecomastia (reduction of breast volume for men)Capsulectomy

Body SurgeryMommy MakeoverGluteal Transfer (BBL)Liposuction360º Liposculpture with Etching360º Liposculpture without EtchingFat Transfer to Buttocks and HipsAnterior LipectomyExtended LipectomyCircular LipectomyAbdominoplastyLabioplastyTorsoplasty

For Weight LossUpper Body LiftLower Body LiftThigh LiftArm Lift

Non-surgicalFillersVaginal RejuvenationFacial Rejuvenation

What part of your body would you like to primarily improve? *

Do you have a maximum budget? If so, please mention your estimated maximum budget. *

Comments

(Questions, Considerations, Etc.)

Criteria and Comments

Photographs Instructions

Please follow the instructions for a prompt and accurate assessment. Fully expose the areas of interest, allowing the doctor to have a clear view for evaluation.

• It is not necessary to capture your face in the images unless it is an area of interest for your procedures.

• For liposuction and abdominoplasty, photos should be in underwear, without covering the abdomen.

• In the case of breast evaluation, without a bra.

Facial procedures

Example for facial procedures

Profile Picture

Frontal view, profile view, and back view with arms extended.

Frontal view, profile view, and back view with arms extended.

Profile Picture

Arms extended as seen in the image.

Arms extended as seen in the image.

Flexion

Two additional photos in flexion to observe the degree of sagging, in both profiles.

Profile Picture

Frontal View

No file chosen

Side View

No file chosen

Back View

No file chosen

2 views in flexion.

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Questions or comments

I have read and understand that the information I provide will only be used for the evaluation of my procedures unless otherwise indicated.Accept

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