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Surgery Quote Questionnaire

It’s mandatory to fill this protocol questionnaire please (be honest, any wrong info can generate changes in your quote):

Name *

First

Last

Age *

Gender *

Male
Female
Transgender

Height *

Weight *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Country

Phone *

Email *

Do you have any of the following conditions? *

High blood pressure
Diabetes
Anemia
Herpes (VHS-2)
Asthma
HIV Postitive or Undetectable
Hepatitis B or C
Lupus
Other

If other condition, please specify and what medication you take:

Have you had any weight loss surgery or other kind of surgery in the past? *

Yes
No

If so, please specify the surgery you had:

Have you had any butt injections: silicon, PMMA or any kind of fillers?

Yes
No

Please specify the surgeries you are looking for. (Feel free to explain your concerned areas)

How did you heard about us? *

Referral
Instagram
Facebook
RealSelf
Official Website

Desired surgery date? *

Date

Time

Front Photo(s) *

Click or drag files to this area to upload. You can upload up to 5 files.

JPG, PNG

Back Photo(s)

Click or drag files to this area to upload. You can upload up to 5 files.

JPG, PNG

Side Photo(s)

Click or drag files to this area to upload. You can upload up to 5 files.

JPG, PNG

Home Page
About Dr Mallol
Gallery
Recovery House
Get a Quote
Blog

Get In Touch

1 (849) 855-7527

[email protected]

Manuel Rueda St. No.12A.
Mirador Norte, Santo Domingo, Distrito Nacional

Office Hours

Monday – Friday
9am to 5pm

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First

Last

Email *

Phone Numbers *

Subject *

Your Message *