Medical Questionnaire – Dr. Carlos Marciales

Medical Questionnaire

Please fill out medical questionnaire with accurate information

Full Name

Email

Phone Number

Desired Procedure

Weight

Height

Age

List any previous surgeries

Are you Anemic?

Yes No

Do you smoke?

Yes No

Medication currently taking

List any Chronic Diseases/Illnesses

Allergies

Please upload 3 photos of scars if any previous surgeries

619.551.6541

Schedule My Consultation

Have Any Questions?

Contact us today for any questions or concerns

Our Mission is transforming Patients From Around the Globe

Schedule a face-to-face video consultation today. Please fill out a form, call our office, or book your aesthetics appointment online today.

Breasts

Body

Face