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Virtual Consultation

Welcome to our Virtual Consultation service.

This approach allows you to discuss your aesthetic goals and receive professional advice without leaving your home.

Our virtual consultations are designed to be comprehensive and private, ensuring you get the personalized attention you deserve.

Your Beauty Journey
Starts here!

Provide us with necessary details about your medical history and aesthetic goals.

Choose Your Language

Interrogation and Clinical History


Please note that all information provided on the form is completely confidential and will only be used for the purpose of providing you with the best possible care.
Formulario

- Personal & Contact Information -

- Personal Health Information-

We strive to provide quality care and services to our patients. During virtual consultations, we request that patients provide us with all relevant medical and supplementary information. This may include any medical history, current medical treatments, medications being used, allergies, and general health information. Additionally, we request any supplementary information that may be relevant to the consultation. This way, we can ensure that our patients receive the best possible care.*(including hormonal contraceptives and hormone therapies)

- Family Medical History-

At our plastic surgery clinic, we understand how important it is to consider any relevant family medical history before beginning any cosmetic procedure. It is important that you tell us if you have a family history of medical conditions, such as heart disease, diabetes, cancer, blood disorders, or any other relevant medical history. Providing us with this information will help us determine the best course of action for your cosmetic procedure.

We take the safety of our patients very seriously and strive to ensure that all of our procedures are performed safely and effectively.
Please select the boxes that apply. Diseases that your relatives have suffered or are currently experiencing.

- Personal Medical History-

Please select the boxes that apply. Diseases that your relatives have suffered or are currently experiencing.

- Gyneco-ostetric history -

Have you been pregnant?

- Personal Habits -

Do you smoke?

- Procedures of Interest -

Facial Surgery
For Weight Loss
Breast Surgery
Non-surgical
Body Surgery

- Criteria to Consider -

 The 3 most important elements of your criteria. (Example: Reduce scarring in certain areas, Wide hips, prioritize definition over volume, etc.)

- Photographs -

Please follow the instructions for a prompt and accurate assessment. Fully expose the areas of interest, allowing the doctor to have a clear view for evaluation.

* It is not necessary to capture your face in the images unless it is an area of interest for your procedures.

* In the case of liposuction and lipectomy, the photos should be taken in underwear.

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(Please upload 3 photos at the same time from your gallery as shown).
Select Photos
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(Please upload 3 photos at the same time from your gallery as shown).
Select Photos
(Please upload 2 photos at the same time from your gallery as shown).
Select Photos
I confirm that the information I provide may be used for evaluation, follow-up contact, and related promotional content from Dr. Díaz Plastic Surgery, unless I request otherwise. Required

check our privacy policy here

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