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DATE: day: ______________/mm:____________________/20________________

Last name: ______________________First Name: __________________Age: _________Gender:___________ Religion:_________________ Occupation: __________________

Birthdate: day:_____/month:_____/year:__________ Nationality: ___________________ Blood Type: ____________Marital Status: __________________________________

Home phone: _______________________Cell Phone: _____________________ E-mail address: ____________________________Employer:_____________________________

Street Address: ____________________________________________________ APT: ____________City:________________ State:__________________ Zip Code:___________

Emergency Contact: _____________________________Relationship to patient: ______________________Telephone:_______________________________________________

Referred by: _________________________ A person, who?

_____________________________________________________________________________________________________________________

PATIENT HISTORY

1) Reason for visit: _______________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

2) Social History:

Alcohol: NONE___OCASSIONAL___MODERATE___EXCESSIVE___ Cigarette Smoking: YES___NO__ PACKS PER DAY ___DRUG USE: __DRUG TYPE: __________________________

3) Pathological:

Medicines, prescribed drugs and supplements consumed within the last month:

Name

Route of Administration

Dose

Frequency

Date of Last Dose

OTHER: Do you take Aspirin? _______________________________ Date of Last Dose: day: _____/month: _____/year: _______comments:______________________________ Do you take AINES (anti-inflammatory)? _____________________ Date of Last Dose: day: _____/month: _____/year: _______comments:______________________________ Please mark with a cross (x) where applicable: Important diseases during childhood: _______________________________________ diseases during adult life________________________________________________ Infections: ______ traumatisms: _____ Transfusions: _______ Bleeding disorders: _____ Circulation disorders: ______ Chronic degenerative diseases: Cancer: ______ Diabetes: ______ arterial hypertension: ______ Heart diseases: _____________ Respiratory diseases: _______________________________________________ Immunological diseases: _____ Emotional Problems: ________Other: ______________________________________________________________________________________ Description of the disease, age of onset, complications and treatment: ______________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Previous Surgery and Date: __________________________________________________________________________________________________________________________ Previous Surgery and Date: __________________________________________________________________________________________________________________________ Previous Surgery and Date: __________________________________________________________________________________________________________________________ Previous Surgery and Date: __________________________________________________________________________________________________________________________

Allergies to medicines, foods, substances: or products such as latex, isodine, adhesive cloth: _____________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Dental work or procedures under local anesthesia: ______________________________________________________________________________________________________ 4) Probable date of the procedure you want to perform: day: ______________/month: ____________________/2019

PROCEDURES

COST

TOTAL COST:

OBSERVATIONS: ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________

_____________________________________________________ FULL NAME AND PATIENT FIRM

______________________________________________________________

DR. RICARDO VEGA MONTIEL

BOARD CERTIFIED PLASTIC SURGEON U.A.B.C / U.N.A.M CED. PROF. AE-0124

VEMONT PLASTIC SURGERY, SIMSA, THE F TOWER, CIRCUITO BURSATI 9043, SUITE 306, ZONA URBANA RIO, TIJUANA B. C. 22010. TEL: (664) 686-55-99

VEMONT PLASTIC SURGERY, SIMSA, THE F TOWER, CIRCUITO BURSATI 9043, SUITE 306, ZONA URBANA RIO, TIJUANA B. C. 22010. TEL: (664) 686-55-99

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