Orthopedic
Surgeries
Mexico

Pre-Consultation Form

We beg you to respond thoroughly to each question, that will allow us to send you an accurate quote in shorter time and will enable our medical team to establish a precise medical diagnosis to evaluate the possibility (or not) to carry out your surgery.

PERSONAL INFORMATION

Full Name:

Age:

Sex:

Address:

City:

Phone:

Country:

Your Email: 

be sure your mail is correctly written

YOUR PROCEDURE(S)

Surgery of interest:

Documentation:

Recent copies of x-rays, scans, diagnosis reports, medical reports will help provide a more accurate estimate & medical opinion.

File Update

This form is secure and all information and uploads will be submitted over a secure connection. This form can upload multiple files. Simply select the file from your computer and it will be added to the list below. If you find it difficult to attach your documents, you can send them directly to us by email: contact@orthopedicsurgeriesmexico.com

MEDICAL INFORMATION

Height:

Weight:

Blood Type:

Do you smoke?

Do you take drugs ?

Do you drink?

Do you take any treatment?

Do you take any medication?

Do you have any allergy?

Are you diabetic?

Are you suffering from cholesterol?

Do you suffer from high blood pressure?

Do you suffer from anemia?

Have you gone through depression?

Did you have any viral illnesses?

Have you ever had a fracture?

Do you exercise?

Have you had any medical surgical procedure(s) before?

MOTIVATION LETTER

How long have you wanted to undergo this type of surgery?

What are your reasons for wanting this surgery?

Have you previously consulted with an orthopedic surgeon? If so, when and under what circumstances

Why did you choose Orthopedic Surgeries Mexico to perform your surgery?

COMMENTS

You have now fully completed your Pre-Consultation Form, please take a moment to look it over one last time to assure that all questions have been answered completely. It is very important that we help you prepare for surgery. Once you are sure that all question are answered, please submit the form.Please enter your full name to verify that all the information you have provided is accurate to the best of your knowledge.

I, authorize Orthopedic Surgeries Mexico and/or his designees to request medical information, if required, as a part of this health history questionnaire. The information that is to be requested from the physicians may include but is not limited to, History and physical exams, Discharge summaries, Consultation reports, Laboratory and image studies.I certify that my health history information is true and correct and that I am not intentionally falsifying my health information or misleading in any way about my current health including intentionally leaving out health information. I further understand that any false statements regarding my medical history could result in cancellation of surgery and I would be responsible for all cost incurred by .

Name:

Date:

Thank you for your confidence