>> FIll Form: Contact Form

Contact Form

Greetings! to achieve your goal, please answer these few questions completely and sincerelly...

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Select your Language:

I declare that the information described below is true and I am
not omitting any additional data.

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Full Name (As in your ID):

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Gender:

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Age:

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Passport or national ID:

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Country where you are currently living?:

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Email:

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Whatsapp Number:

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Requested Surgery:

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Prospected date of Surgery (Month - Year):

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Do you already have or need a lodging or recovery house? If so what is it?:



Height (Select centimeters OR Feet/Iches)

Centimeters:

- OR - Feet:

Inches:

Weight (Select kilos OR pounds)

Kilos:

- OR - Pounds:

BMI (Body Mass Index):



please check YES or NO on any of these conditions

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Smoker:

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HIV patient?:

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Heart attack:

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angina pectoris:

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Single Kidney?:

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Rheumatoid arthritis:

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lupus erythematosus:

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Sjogren:

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Scleroderma:

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Polymyositis:

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Dermatomyositis:

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Polyarteritis Nudosa:

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Diabetes:

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Deep Venous Thrombosis:

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Sickle Cells trait / Sickle Cells desease:

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high blood pressure:

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Asthma:

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Pregnancies and abortions:

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Previous surgeries:

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Some other health condition:

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Do you take any medication?:

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Allergy to any medication?:

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You have biopolymers?:



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