Solicitud de Evaluación - Dr. Martin B. Robles Mejía

Name*
Names) Surnames)
Sex*
- Female
- Male
Birthdate*
Are you a local or international patient?*
- Virtual Consultation (only if you live abroad)
- In-person consultation (in office)
Nationality*
E-mail*
Mobile*
ID / Passport
Address*
Street Address City State / Province / Region Country
Profession*
Instagram user:
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Age
Current Weight (lbs)*
Please enter a number from 80 to 300.
Height (ft.,in.)*
Blood type*
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Height Inch
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BMI
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Current Weight (kgs)
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Height (cm.)
Do you suffer or have you suffered from any illnesses or health conditions?*
- Yes
- No
Please specify which diseases
Select all that apply
- Arrhythmias
- Asthma
- Bronchial asthma
- High cholesterol
- Constipation
- Depression
- Diabetes
- Psychiatric Illness
- Heart disease
- HIV (AIDS)
- Hepatitis
- Arterial hypertension
- History of anemia
- Heart attacks
- Blood pressure
- Bleeding
- Thyroid
- Thrombophlebitis
- venous thrombosis
- Varicose veins
- Others
Please specify your psychiatric condition*
Please specify your health problem*
Do you have a family history of any illness or health condition?*
- Yes
- No
Family History: Indicate if you suffer or have suffered from illnesses of close relatives (father, mother, siblings and children).
Do you take any medications or supplements regularly?*
(for blood pressure, antidepressants, protein, weight loss supplements, vitamins)
- Yes
- No
Specify the medications/supplements you take*
Are you or a family member a carrier or suffering from FALCEMIA?*
- Yes
- No
- Family member
Please specify your or your family member's falcemia condition.*
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Have you had any previous surgery? Select the ones that apply.
- General Surgery (bariatric, appendectomy, gallbladder removal, etc.)
- Plastic Surgeries (breast reduction, liposuction, etc.)
Have you had any cosmetic or general surgery before?*
Example: liposuction, cesarean section, barbaric, etc.
- Yes
- No
How many surgeries have you had before?*
Please describe the type of surgery, the date and if there were complications in each one.
1st Surgery (type)*
Date of 1st Surgery*
Did you have complications in the 1st surgery?*
- Yes
- No
Specify the complications of the 1st Surgery*
2nd Surgery (type)*
Date of 2nd Surgery*
Did you have complications in the 2nd surgery?*
- Yes
- No
Specify the complications of the 2nd Surgery*
3rd Surgery (type)*
Date of 3rd Surgery*
Did you have complications in the 3rd surgery?*
- Yes
- No
Specify the complications of the 3rd Surgery*
4th Surgery (type)*
Date of 4th Surgery*
Did you have complications in the 4th surgery?*
- Yes
- No
Specify the complications of the 4th Surgery*
5th Surgery (type)*
Date of 5th Surgery*
Did you have complications in the 5th surgery?*
- Yes
- No
Specify the complications of the 5th Surgery*
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Did you have any complications in said cosmetic surgery?*
- Yes
- No
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Specify about the complication you had in your previous cosmetic surgery*
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Previous General Surgery*
Please specify the type of surgery(s) performed
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Previous general surgery date*
MM slash DD slash YYYY
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Did you have any complications in said general surgery?*
- Yes
- No
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Specify about the complication you had in your previous general surgery*
How many pregnancies have you had?*
How many children have you had?*
How was your birth?*
Date of your last birth*
Do you take contraceptives?*
- Yes
- No
Type of contraceptive*
Are you allergic to any medications?*
- Yes
- No
Which medication(s) are you allergic to?*
Do you smoke? Or did you smoke before?*
- Yes
- No
- used to smoke
What do you smoke or did you smoke? Ex: cigarette, vape, etc…*
- Cigarettes
- Hookah
- Vape / Electronic Cigarette
- Cigar/Tobacco
- Dope
How often do you or did you smoke and how many years have you/had you been smoking?*
Drink alcohol?*
- Yes
- No
How often do you drink alcohol?*
Have you had COVID?*
- Yes
- No
What procedures do you want to have done?*
To see a description of each procedure, enter here.
- Abdominoplasty
- BBL – Gluteal Fat Graft
- Brachioplasty
- Cruroplasty
- Breast Fat Graft
- J-Plasma
- Facial Lift
- Double Chin Lipo
- Lipo Vaser
- Arm Liposuction
- Liposculture
- Augmentation Mammoplasty
- Abdominal Marking
- Mammoplasty with Implants
- Mini Abdominoplasty
- Breast Reduction
- Others
Another procedure of interest*
Please send us 5 photos in the following positions: standing frontally, standing sideways, standing back, sitting front, sitting sideways, and face if applicable for your procedure.

Note: without underwear or small underwear. Without showing your face.
Front Photo*
Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.
Side Photo*
Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.
Back Photo*
Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.
Front Sitting Photo*
Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.
Side Sitting Photo*
Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.
Additional Photo
Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.
When would you like to have this surgery?*
Preferred Language*
Comment:
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Lead Source
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Consent
Please read the terms carefully

I, {Name (First Name):16.3} {First Name (Surname):16.6}, bearer of the identity and electoral card and/or passport No. {Cedula Number:107}{Passport Number:108} , of nationality {Nationality:110}, on the day {date_dmy}. I DECLARE UNDER FAITH OATH, I am the only one responsible for any damage caused to me by any omission to the bad information that I have provided in this document after having carefully read the questions asked by Doctor Martin Robles, and I understand that hiding any type of medical information from this or its medical staff could put my life and health at risk, as well as my obligation to notify any change or alteration to the information provided here.

Patient's signature

______________________________
{First Name (First Name):16.3} {First Name (Last Name):16.6}

Evaluation Request

Please describe the type of surgery, the date and if there were complications in each one.

Consent

Please read the terms carefully

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