APPLICATION Regain health and loose an average of 60-80% of your excess weight fast and safely! Application En este formulario se encuentra la aplicación de todos los servicios en inglés 1General2Health Details3Medical History4Surgical History5General Health6References Have you received any treatment with us before?* Yes No Name* Last name* Biological Sex*Select one of the followingFemaleMaleBirth Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Phone 1*Phone 2Email* Address Zip CodeCity State* Country* Services*Services *UrologyPlastic SurgeryBariatric SurgeryDentalProcedure*Procedure *Treatment for Erectile DysfunctionGreen Light Laser SurgeryReversal of VasectomyProcedure*Procedure *Urinary Incontinence SurgeryProcedure*ProcedureMommy MakeoverLiposculptureBreast AugmentationBreast LiftingAbdominoplasty (Lipectomy)Gluteal Lift (Brazilian Butt Lift)Facial Stretching (Rhytidectomy)BlepharoplastyBrachioplastyRhinoplastyThigh LiftBotoxHyaluronic AcidChemical ExfoliationProcedure*ProcedureGastric SleeveGastric BalloonRevision SurgeryGastric BypassDuodenal switchSADIProcedure*Procedure *FillingsCrowns/VeneersDenturesRoot Canal TreatmentCleaningExtractionsImplant ProceduresProcedure*Procedure *FillingsCrowns/VeneersDenturesRoot Canal TreatmentCleaningExtractionsImplant ProceduresPackages*PackagesBasicPremiumPremium PlusPackages*PackagesBasicPlusHiddenIn order to give you a quote we require the following pictures of you from the neck down with no clothes. You can cover your privates with a stickerFront* Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 10 MB, Max. files: 4. Maximum upload file size: 8MBBack* Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 10 MB, Max. files: 4. Maximum upload file size: 8MBLeft side* Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 10 MB, Max. files: 4. Maximum upload file size: 8MBRight side* Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 10 MB, Max. files: 4. Maximum upload file size: 8MBHiddenIn order to give you a quote, the following photos are required to get a better idea of the requested service Showing Teeth* Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 10 MB, Max. files: 4. Maximum upload file size: 8MBOpen Mouth, Teeth up* Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 10 MB, Max. files: 4. Maximum upload file size: 8MBOpen Mouth, bottom Teeth* Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 10 MB, Max. files: 4. Maximum upload file size: 8MBShowing Teeth, Mouth Open* Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 10 MB, Max. files: 4. Maximum upload file size: 8MBEmergency ContactName* Phone** Required Select your preferred measurement system* Metric ( kg - meters ) Imperial ( lb - in ) Max weight (kg)*Current weight (kg)*Height (meters).*BMI*Max weight (lb)*Current weight (lb)*Height (ft)*BMI*Do you take any medications/drugs?* Yes No List*Name of MedReasonDoseFrecuency Do you take, or have you taken in the past Blood-thinners?* Yes No Explain the reason* Do you suffer from acid reflux?* rarely occasionally frequently no Do you have any allergies?Penicillin* Yes No Sulfa Drugs* Yes No Iodine* Yes No Tape* Yes No Latex* Yes No Aspirin* Yes No Other Have you had or do you have now?Addictions* Yes No Which one?* High lipid levels* Yes No Diagnostic date* Treatment* Arthritis* Yes No Diagnostic date* Treatment* Cancer* Yes No Diagnostic date* Treatment* Cholesterol and triglycerides* Yes No Diagnostic date* Treatment* Stroke* Yes No Diagnostic date* Treatment* Diabetes* Yes No Diagnostic date* Treatment* Coronary Artery Disease* Yes No Diagnostic date* Treatment* Liver disease* Yes No Diagnostic date* Treatment* Lung Disease* Yes No Diagnostic date* Treatment* Renal disease* Yes No Diagnostic date* Treatment* Thyroid disease* Yes No Diagnostic date* Treatment* Hypertension* Yes No Diagnostic date* Treatment* Any other illnesses* Yes No Other illnesses*What other illness? *Diagnostic date*Treatment* Gynecological HistoryDate of last menstrual period:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Bleeding was* Normal Light Heavy Irregular Have you been pregnant?* Yes No How many times?C-sectionDo you use any type of birth control?* Yes No Birth controlTypeHow long have you used this birth control? Are you presently, or have you ever taken hormones?* Yes No HormonesTypeHow long have you been using hormone type? Are you pregnant? or is there a possibility of you being pregnant?* Yes No Have you had any previous surgery?* Yes No Previous surgeries*What surgery?*What was your age?*What year was it performed?*Any complications?* Have you ever had bariatric surgery?* Yes No Previous bariatric surgery*Which one?*What was your age?*What year was it performed?*Any complications?* Have you ever had a problem with an anesthetic?* Yes No Describe the problems*Have you ever had bariatric surgery?* Yes No Bariatric surgeries*Type of surgery*Year performed* Have you ever had plastic surgery?* Yes No Plastic Surgeries*Type of surgery*Year performed* Have you ever had a prostate surgery?* Yes No Prostate surgeries*Type of surgery*Year performed* Have you ever had pelvic surgery?* Yes No Pelvic Surgeries*Type of surgery*Year performed* How long ago was this surgery (vasectomy)?Specify the year* Where was it done?* Did you have any complications (vasectomy)?* Yes No Specify*Do you have any discomfort or pain in your testicles?* Yes No When did you realize the discomfort?* Has any testicular operation been performed other than vasectomy?* Yes No Testicular operations*Year*Any complications?* Currently...Do you smoke cigarettes?* Yes No Do you vape?* Yes No sometimes Amount Number of years Have you quit smoking?* Yes No How long? Do you drink alcohol?* Yes No Amount?* Use recreational drugs?* Yes No Amount?* Have you ever used intravenous drugs (or skin-popping)?* Yes No Are you easily fatigued?* Yes No Do you have shortness of breath?* Yes No Do you have asthma?* Yes No Do you use a B-PAP or C-PAP while you sleep?* Yes No Do you exercise?* Yes No Exercise*TypeHow long?How frecuent?Hours per day Hours you sleep at night* Do you take sleeping pills?* Yes No Do you suffer from anxiety / depression?* Yes No Do you take pills for anxiety / depression?* Yes No Do you feel under stress?* Yes No Do you have erections in the morning?* Yes No How many per week? Do you have problems getting erections?* Yes No Since when? Describe your problemDo you have problems maintaining an erection?* Yes No Do you take Viagra?* Yes No When did you began?* How did the pills work?* How often?* How do you take them?* Do you take any natural remedy for Erectile dysfunction?* Yes No What kind?* How did it work?* Where did you get them?* Has medication been injected for dysfunction erectile?* Yes No How many times?* How did it work?* Have you had an erection longer than 6 hours?* Yes No When?* How was it resolved?* Did you get medical attention?* Do you suffer from penile curvature?* Yes No How intense?* Which direction?* Does it hurt?* Does it prevent intercourse?* Has PRP been injected for erectile dysfunction?* Yes No Have you received stem cell treatment for erectile dysfunction?* Yes No Have you received vascular regeneration therapy with low intensity wave therapy for erectile dysfunction?* Yes No Has there been prostate cancer in your family?* Yes No Has the PSA test ever been done?* Yes No When?* What was the result?* Have you ever had a prostate biopsy?* Yes No When?* Where?* What was the result?* Do you get up at night to urinate?* Yes No How many times?* Drips / spills after urinating?* Yes No Do you urinate frequently? (Every 2 hours or less)* Yes No Does it take a long time for urine to come out?* Yes No When urinating ...Does the urine stream pause frequently?* Yes No Is the urine stream very thin?* Yes No Is the urine stream weak?* Yes No Do you have to push?* Yes No Have you ever bled?* Yes No Have you had to use a urinary catheter?* Yes No For how long?* Have you ever had a urinary infection?* Yes No What antibiotic(s) did you take?* Do you suffer from urinary incontinence?* Yes No Since when?* Do you take medications for prostate obstruction or BPH (Benign Prostate Hypertrophy)?* Yes No Type* Since when?* Do you take Viagra or any medication for erectile dysfunction?* Yes No Since when?* Has it worked?* How often?* How do you take it?* How did you know about us?References* Google Facebook Youtube / Vimeo Twitter Web Forums Instagram Radio Email Referred by a Friend Other Friend's Name* Specify media* Promo codeEnter if you have a promotional code * By submitting this form, it is valid that the information provided to "J.L. Prado Surgical Center" is real and has not been altered in any way since that could jeopardize my health