Pre-Procedure Assessment

Name

Passport Number

Last Name

Country of Origin

Date of Birth

Weight

Marital Status

Type of Procedure

Cosmetic Procedure

Bariatric Procedure

Dental Procedure

Gender Affirmation

Height

Highest Level of Education

Tentative Travel Date

Blood Type

Current Profession

Are you Pregnant?

Health Insurance Information (if any)

Do you have any Allergies? If yes, explain

Do you smoke/vape, drink alcohol and/or use drugs including marijuana? If yes, how often?

Have you been hospitalized in the last 12 months? If yes, explain.

Are you suffering from a medical condition, illness, disability, or injury? Have you had COVID-19 or exposed to it in the last 30 days? If yes, explain.

Please list all past surgeries with the year they took place

Please list all current medications, including vitamin and birth control

Please list any other medical conditions the medical team should know about

I hereby authorize My Body by Design LLC to disclose the protected health information on this form to a My Body by Design LLC contracted medical professionals.

By submitting this form, I consent to My Body by Design LLC and the clinic's medical team to use my data contained in this questionnaire for purposes limited to medical use only. I understand that my personal information will be treated separately and confidentially. I declare that the info I’ve provided is accurate & complete.

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