Today's Date:		  
Full Name:
Email:
Age: Date of Birth:   
Height: Weight:
Address/residence:
Phone number, if desired. Include area code:
Country:
Sex: Male Female
Current Medications (Include vitamins and supplements):
Medical Conditions:
Medical Doctors Name, address and phone number:
Previous surgeries:
Any previous problems with Anesthesia? (Please explain)
Significant wt. Loss or gain? (Please explain)
For what areas that you are interested in having surgery performed? Please be specific:
Can you provide/send digital photos of these areas?
Have you had any recent Abnormal Laboratory reports? When was your last lab work done? Please give specific results.
At what time do you want to come to Costa Rica for your Surgery?

  


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For comments or information, please fill in our Infomation Request Form, or contact us at:
E-mail: E-Mail: info@cosmetic-cr.com // From de U.S Call: (011506) 2223-9933 • Fax Number (011506) 2223-9171 // P.O. Box: 657-1005 San José, Costa Rica
© 2005 Rosenstock-Lieberman Center, a Costa Rican company. Specialists in plastic surgery, facial plastic surgery, Cosmetic plastic surgery and more.
 
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