Lotus Med Group Surgery Application Form

Answer the following questions below and begin the journey to the change you deserve.

Please complete this questionnaire. We will use the information provided to evaluate your current health status and reduce any risk in the procedure.

1.- PERSONAL INFORMATION

We'll use this information to create your profile.

Doctor of your interest?:

First Name(s)

Last Name

What's your phone number?

Only 10 numbers

WhatsApp

Only 10 numbers, If you don't have any, leave blank

Email

Please enter your email

Date of Birth?

Please enter a valid date

Sex

Which City/Place are you contacting us from?

Ex. Tijuana, Baja California

2.- SERVICE OF YOUR INTEREST

Details about the surgery or procedure you're interested in.

What type of procedure are you interested in?

What's your current weight?

Ex. 160 lbs

What's your current height?

Ex. 5'6 ft.

Do you smoke, or used to smoke (also weed)?

If YES, How many cigarettes per day?

Ex. 5

How long have you been smoking for? Leave it blank if you don't smoke

Ex. 5 years.

Do you have any illness that requires ongoing treatment? Describe which one.

What medications or vitamins do you currently take?

3.- PAST SURGERIES

If you've had past surgeries, please describe them below.

Have you had any surgeries in the past?

If yes, please describe the type of surgery & dates.

Please mention the medical facility and your surgeon:

Have you had complications in your surgeries or anesthesia? Please describe.

4.- FOR WOMEN ONLY

Are there any posibilities of you being pregnant?

Would you like to become pregnant in the future?

How many pregnancies have you had?

Ex. Two pregnancies.

How many children have been born alive? (Only for those who have been pregnant).

Ex. Two alive.

How many were natural childbirth? (Only for those who have been pregnant).

How many were caesarian operations?

Ex. 2.

Have you had spontaneous abortions?

Have you had any contraceptive or hormonal treatment in the last 2 years? Describe

5.- IF INTERESTED IN BREAST SURGERY

Answer these questions only if you're interested in breast surgery.

What is your current bra size?

What is your desired bra size?

Have you had a breast ultrasound or mammography?

If YES, What were the results?

6.- PAST BARIATRIC SURGERIES

This section is only for patients who lost a lot of weight with bariatric surgeries. If this is not your case, you can finish your application.

What type of bariatric surgery did you have?

How long ago?

Did your surgery take place in Tijuana, Mexico?

Please mention the bariatric center, or your bariatric physician.

What was your highest weight before surgery?

How long have you been in the same weight for?

7.- Pictures' Section

Example

INSTRUCTIONS FOR UPLOADING IMAGE:

1. Select the button "Upload Files" below.

2. Select the pictures that you want to send.

PICTURES:

If you can't upload the pictures, you can also send your pictures to our email address at filtro@tjlipo.com

By clicking "Submit Information" you accept the use of this information by Lotus Med Group team, for medical purposes as well as statistics. In addition, you accept our privacy policies, and the terms and conditions. We will never share your information.

8.- CONTACT

How did you hear about us?