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US (619) 494-2215
MX +52-664-414-9011
US (619) 494-2215
MX +52-664-414-9011
World class plastic surgery in Tijuana, MX
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Plastic Surgery for Women
Breast Surgery
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Urinary Incontinence
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Alejandro Quiroz, MD
Juan Carlos Fuentes MD
Carlos Castañeda, MD
Francisco Bucio, MD
Enrique Quiros Lim, MD
Alberto de la Fuente García, MD
Javier Saldaña MD
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Contact
Pricing
Special Promotions
World class plastic surgery in Tijuana, MX
Toggle Navigation
Our Clinic
Services
Plastic Surgery for Women
Breast Surgery
Facial Rejuvenation
Body Contouring
Tummy Tuck
Vaginal Rejuvenation
Mommy Makeovers
Juliet Vaginal Laser
Urinary Incontinence
Plastic Surgery for Men
COSMED for Him Facial Rejuvenation
Body Enhacement
Gynecomastia
Hair Transplant
Urology
Plastic Surgery After Weight loss / Post Bariatric
Face Lift
Body
Neck
Dermatology / Medi Spa
Botox®
Coolshaping
Medical Treatments
Cosmetic Treatments
Phibrows™ Microblading
Laser Tattoo Removal
Hair Transplant & Restoration
Spa Services
Skin Care Products
Meet our Doctors
Alejandro Quiroz, MD
Juan Carlos Fuentes MD
Carlos Castañeda, MD
Francisco Bucio, MD
Enrique Quiros Lim, MD
Alberto de la Fuente García, MD
Javier Saldaña MD
Gallery
Patient Resources
Facilities, Travel & Accommodations
Why Surgery in Mexico?
What to Expect Before and After Surgery
After Care
FAQ’s
Patient Health Information and Disclaimers
Media
Testimonials
Free Virtual Consultation
Blog
Contact
Pricing
Special Promotions
World class plastic surgery in Tijuana, MX
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ID Form Patient | VIDA Wellness and Beauty
Webmaster
2024-11-19T10:23:11-08:00
Formato Identificacion Cosmed
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2
50%
Sobre Ti / About You
Fecha / Date
MM slash DD slash YYYY
Correo Electronico / Email
*
Name / Nombre
*
First / Nombre
Last / Apellido
Edad / Age
Fecha de Nacimiento / Birthday
*
MM slash DD slash YYYY
Sexo / Gender
*
Telefono / Phone
*
Celular / Mobile
Direccion / Address
Calle / Street
Ciudad / City
Estado / State
Tu Cita / Your Appointment
Que doctor Visitas? / What doctor are you visiting?
Dr. Quiroz
Dr. Fuentes
Dr. Castañeda
Dr. Bucio
Dr. Enrique Quiros
Dr. de la Fuente
Dr. Juan Sanchez
Dra. Nathalie Beltran
Dr. Diego Sanchez
Dra. Adriana Garcia
Dr. Saldaña
Dr. Medina
Dra. Gabriela Rodriguez
Medispa
Kaloni
Dental
Motivo de la consulta / Reason for Consultation
Contacto de Emergencia / Emergency Contact
Contacto de Emergencia / Emegency Contact
Telefono / Phone
Direccion / Address
Calle / Street
City / Ciudad
Estado / State
Salud en General / General Health
Salud en General / General Health
Excelente / Excellent
Buena / Good
Regular
Mala / Bad
Alergias Medicas / Medical Allergies
Enfermedades / Illneses
Anemia / Anemia
Yes
No
Problemas del corazon / Heart Problems
Yes
No
Ataque al corazon / Heart Attack
Yes
No
Taquicardias / Tachycardia
Yes
No
Alta Presion / High Pressure
Yes
No
Dolor de pecho / Chest Burn
Yes
No
Electrocardiograma anormal / Anormal Electrocardiogram
Yes
No
Fiebre Reumatica / Preumatic Fever
Yes
No
Problemas en los Pulmones / Lung Issues
Yes
No
Dificultad para respirar / Breathing problems
Yes
No
ASma / Asthma
Yes
No
Bronquitis / Bronchitis
Yes
No
Enfisema Pulmonar / Pulmonary Emphysema
Yes
No
Problema en los riñones / Kidney issues
Yes
No
Cancer
Yes
No
VIH / HIV
Yes
No
Problemas cardiacos en familia / Family Cardiac Problems
Yes
No
Hepatitis
Yes
No
Diabetes
Yes
No
Varices / Varicose Veins
Yes
No
Tratamiento Psiquiatrico / Psyquiatric Treatment
Yes
No
Tratamiento de Cortisona / Cortisone Treatment
Yes
No
Bebidas Alcoholicas / Alcoholic Beverages
Yes
No
Cuantas por semana / How many Weekly
Fuma? / Smoke?
Yes
No
Cuantos por dia / How many Daily
Usa Drogas? / Do you use Drugs?
Yes
No
Cuales? / Which ones?
Ejercicio? / Exercise?
Yes
No
Problemas en los ojos? / Eyes Issues?
Yes
No
Problemas en el Higado? / Liver Issues?
Yes
No
Otros / Other
Yes
No
Past Procedures
Has sido Hospitalizado? / Have you been Hospitalized?
Yes
No
En caso positivo, especifique / If Yes, Specify
Past Procedures
Cirugia / Surgery
Fecha / Date
Anestesia / Anesthesia
Complicaciones / Complications
Add
Remove
Ha estado enfermo de gravedad el año pasado? / Have you been seriously ill in the past year?
Yes
No
En caso positivo, especifique / If Yes, Specify
Embarazos / Pregnancies
Si es mujer por favor responda las siguientes preguntas / If you are a woman please answer the following questions
Esta embarazada? / Are you pregnant?
Yes
No
Ha estado embarazada? / Have you been pregnant?
Yes
No
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