Solicitud de Evaluación - Dr. Martin B. Robles Mejía

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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 ZIP / Postal Code 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

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

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

Specify the medications/supplements you take*

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

Yes

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

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*

MM slash DD slash YYYY

Did you have complications in the 1st surgery?*

Yes

Specify the complications of the 1st Surgery*

2nd Surgery (type)*

Date of 2nd Surgery*

MM slash DD slash YYYY

Did you have complications in the 2nd surgery?*

Yes

Specify the complications of the 2nd Surgery*

3rd Surgery (type)*

Date of 3rd Surgery*

MM slash DD slash YYYY

Did you have complications in the 3rd surgery?*

Yes

Specify the complications of the 3rd Surgery*

4th Surgery (type)*

Date of 4th Surgery*

MM slash DD slash YYYY

Did you have complications in the 4th surgery?*

Yes

Specify the complications of the 4th Surgery*

5th Surgery (type)*

Date of 5th Surgery*

MM slash DD slash YYYY

Did you have complications in the 5th surgery?*

Yes

Specify the complications of the 5th Surgery*

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Did you have any complications in said cosmetic surgery?*

Yes

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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

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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

Type of contraceptive*

Are you allergic to any medications?*

Yes

Which medication(s) are you allergic to?*

Do you smoke? Or did you smoke before?*

Yes

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

How often do you drink alcohol?*

Have you had COVID?*

Yes

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*