Medical Association of Guadalajara

MEDICAL QUESTIONNAIRE

Based upon your medical questionnaire, we can give you a price quote and additional information about the procedure in which you are interested. We will also include the days needed for post-op recovery before returning home. Please give us basic information regarding your medical history, and please indicate the procedures you wish. We will promptly reply with prices and more information.

In order to accurately quote a price, photos of the area of your interest may be necessary. We respect your privacy and understand the inconvenience of sending sensitive photos by email, so we will ask for them only if necessary. You may, of course, send photos to us at any time. Please send them as an email attachment to info@medicalassociationofguadalajara.com.

Upon receiving this Medical Questionnaire, our doctors will review everything and an estimate will be sent through our patient coordinator. You may rely on this estimate as being accurate and factual. Later adjustments to the quote can always be made by mutual agreement with our doctors during your pre-op examination, but the price quoted by email will always be our correct price for the procedure.

Pre-op consultations are generally the same day of your arrival, if arriving early enough in the day. Otherwise, you can relax for the evening at your hotel and see us the next day. Pre-op consultations are normally in the late afternoon. Your surgery will usually be performed the next day.

Medical check-ups prior to surgery can be done here at the hospital, or at home. Complete facilities are available at the hospital to do all required medical tests quickly and at a nominal cost following you pre-op consultation.

Please complete the following and submit to us:

* First Name:

* Last Name:

* Email:

Sex:

Male Female

Age: years

Weight:

Height

Other

Please list any previous surgeries with dates

How is your general health?: Excellent Good Fair Poor

Do you have any particular health problems? If yes, please explain:

Any allergies? ( please specify ):

Any negative experience with anesthesia?. If so, please explain:

Medicines you take at present

Do you use tobacco?

Please list below any specific comments or questions you may have:

Please give us a preferred date and a secondary date, if possible, for your procedure:

Preferred date:

Secondary date:

Thank you. We will promptly replay with answers to any questions you may have. A general overview of your requested surgery, a price quote, and availability of your requested dates will also be sent.

The * denotes mandatory field