Please give us information about yourself so we can answer your specific questions. The following information is required prior to being considered for any type of surgery. Please fill out this questionnaire and send it to the Rosenstock Center. Also, though not a requirement, you may email us a photo of the area you would like to have surgery. If it is your face, please take one front view, and one from the side on a .jpg format . Please send your photo separately to rrosenstock@arrivacostarica.com

Personal information:

Name:  

Sex:  M    Age:  yrs.   Present Weight , Height

Email address:   Phone:   

Previous and actual illness: Have you ever suffered one or more of the following illnesses?

Heart diseases
Epilepsy
Diabetes
Asthma
High blood pressure
Coagulation disorders
Ulcer / Gastritis

Other:

Are you allergic to anything?

No   Yes,

Previous surgeries ( Aesthetic or others )

Have you had any surgeries in the past? If so, when? (please give some detail):

Previous psychiatric history: Have you seen a psychiatrist in the last five years? If so, please explain:

Consumption: What is your daily consumption of the following:

Coffee or Tea:   cups daily
Tobacco:         
cigarettes daily
Alcohol: 
          glasses daily

Actual Medication:

Medicines you take at present:

How many aspirins (or aspirin products) do you take daily?: 

If you take vitamins, please specify:

What is the surgery procedure you wish to have:

BODY:

Arm lift
Buttock Augmentation
Liposuction
Thigh Lift
Tummy Tuck

WRINKLE TREATMENT:

Botox
Chemical Peel
Laser Resurfacing

BREAST SURGERY:

Breast Augmentation
Breast Lift
Breast Reduction

FACIAL:

Ear Surgery
Eyelid Surgery
Face Lift
Forehead Lift
Nose Surgery
Skin Resurfacing

HAIR:

Hair Transplant

OTHER:

Buttock fat graft
Chin Implant
Cheekbone Implant
Facial fat graft
Lip Embellishment


OTHER:

Do you have any specific concerns or questions about the procedure

Females: OBGY History:

Availability: Please check surgery availability, your preferred dates:

1st choice   2nd choice

Thank you. We will respond promptly with prices and availability.


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