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*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Phone 1*Phone 2Email* Find out about our latest promotions, news, and procedures * indicates required Email Address * /* real people should not fill this in and expect good things - do not remove this or risk form bot signups */ Address Zip CodeCity State* Country* Services*Services *UrologyPlastic SurgeryBariatric SurgeryDentalOncologyProcedure*Procedure *CircumcisionVasectomyVasectomy reversalHydroceleVaricoceleGenital Warts removalTesticular tumorsTransuretral Resection of the ProstateTransuretral Resection of Bladder TumorsLaser Cysto Lithotripsy of Bladder stonesLaser UreteroscopyLaser Kidney UreteroscopyPercutaneous NephrolithotomyCystoscopyColpoplastyNephrectomyTreatment for Erectile DysfunctionGreen Light Laser SurgeryReversal of VasectomyPlease upload a photograph to relate it to the service you require.*Accepted file types: jpg, jpeg, png, gif.Please upload a photograph to relate it to the service you require.Accepted file types: jpg, jpeg, png, gif.Procedure*Procedure *Urinary Incontinence SurgeryProcedure*ProcedureMommy MakeoverLiposculptureBreast AugmentationBreast LiftingAbdominoplasty (Lipectomy)Gluteal Lift (Brazilian Butt Lift)Facial Stretching (Rhytidectomy)BlepharoplastyBrachioplastyChin LipoRhinoplastyThigh LiftBotoxHyaluronic AcidChemical ExfoliationProcedure*ProcedureGastric SleeveRevision SurgeryGastric BypassGastric BalloonDuodenal 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: 1. 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: 1. 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: 1. 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: 1. 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: 1. 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: 1. 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: 1. 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: 1. Maximum upload file size: 8MBFirst visit to the dentist?* Yes No HiddenLast visit to a dentist?Add-OnsLast visit to the dentist? MM slash DD slash YYYY X-ray?* Yes No Reaction to any dental anesthetic?* Yes No HiddenTo which one?* Yes No To which one?* HiddenHow many times do you brush per day?* Yes No How many times do you brush your teeth each day?*How would you describe your dental health?* Good Fair Poor Do you do or have you done the following? Grinds/Clenches teeth Locked jaw Dental sensitivity Swallowing difficulties Mouth breather Smokes Noises in your temporomandibular joint Habit (nail-biting, finger-sucking, etc.) Gum bleeding while brushing Pain in your temporomandibular joint Have you used drugs? Oral hygiene problems Facial or mouth injury Prior orthodontic treatment Frequent nausea or vomiting Do you consume alcohol? Other Dental sensitivity* Cold Heat Sweet How often do you smoke?* Have you used drugs? Which ones?* How often have you used drugs?* Do you consume alcohol, and how often?* Other* What is the reason for your visit?* Are you satisfied with the appearance of your smile?* Yes No HiddenWhy?* Yes No Why?* Has any of your family members received orthodontic treatment?* Yes No Plastic Surgery Add OnsAdd-OnsFillersBotoxExtra LipoOtherFor Plastic Surgery Add-ons Drop files here or Select files Accepted file types: jpeg, jpg, gif, png, Max. file size: 1,000 MB, Max. files: 4. Maximum upload file size: 8MBEmergency ContactName* Phone*Reason for ConsultationFor Diagnosis* Yes No If yes, what prompted you to consult? For Treatment* Yes No If yes, what is your diagnosis? For a Second Opinion* Yes No If yes, what is the reason? Have you been evaluated by an oncology service?* Yes No If yes, what is the reason? For Complementary Services* Yes No Which service are you interested in? Main reason for consulting outside your country Waiting time Communication with healthcare providers Financial reasons Other causes Other Causes For Palliative Treatments* Yes No If yes, what is the reason? Do you have confirmatory diagnostic studies?* Yes No If yes, which ones? Have you been classified according to your cancer in any stage of the AJCC?* Yes No What type and in what area? Approximately When? MM slash DD slash YYYY Do you have laboratory studies?* Yes No Please upload laboratory studiesMax. file size: 1 GB.Have you had tumor markers tests?* Yes No Please upload tumor marker testsMax. file size: 1 GB.Have you undergone any genetic testing?* Yes No Please upload genetic testingMax. file size: 1 GB.Do you have X-ray studies?* Yes No Please upload x-ray studiesMax. file size: 1 GB.Have you undergone any biopsies?* Yes No What type and in what area? Please upload biopsy studiesMax. file size: 1 GB.Do you have immunohistochemistry studies?* Yes No Which ones? Please uppload immunochemistry studiesMax. file size: 1 GB.Do you have imaging studies?* No CT scan MRI PET CT Others Which ones? Please upload imaging studiesMax. file size: 1 GB.Have you received oncological treatment?* Yes No Which ones? Aproximently when? MM slash DD slash YYYY Have you undergone any surgery for cancer-related tumors?* Yes No Which ones? Aproximently when? MM slash DD slash YYYY Have you received medical oncology treatment with chemotherapy?* Yes No Which treatment? Reason Aproximently when? MM slash DD slash YYYY Have you received radiation treatment?* Yes No Reason Which treatment? Aproximently when? MM slash DD slash YYYY Have you received hormone therapy treatment?* Yes No Reason Which one? For how long? Have you received immunotherapy management?* Yes No Reason Aproximently when? MM slash DD slash YYYY Have you received management for palliative care or pain specialists?* Yes No Reason Which treatment? Aproximently when? MM slash DD slash YYYY Do you have vascular access like a port-a-cath?* Yes No Which one and when was it installed? Approximately when did you receive maintenance? MM slash DD slash YYYY Do you have any preference for a specific oncological treatment?* Yes No Which one? Have you had previous experiences with friends or family members with cancer?* Yes No With whom? Approximately when? MM slash DD slash YYYY In case of experience with oncological diseases, What was the final outcome of the treatment? Do you have any other associated medical condition?* None Diabetes Mellitus (DM) Hypertension (HTN) Hepatitis Asthma Epilepsy HIV Hypothyroidism Others * 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)*Height (in)*BMI*Do you take any medications/drugs?* Yes No List*Name of MedReasonDoseFrecuency Have you experienced reflux issues/heartburn?* Yes No Do you take, or have you taken in the past Blood-thinners?* Yes No Explain the reason* 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* Incomplete Emptying*How often have you had a sensation of not emptying your bladder completely after you finish urinating?Incomplete Emptying *0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half time4 = More than half the time5 = Almost alwaysFrecuency*How often have you had to urinate again less than two hours after you finished urinating?Frecuency *0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half time4 = More than half the time5 = Almost alwaysIntermittency*How often have you found you stopped and started again several times when you urinated?Intermittency *0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half time4 = More than half the time5 = Almost alwaysUrgency*How dificult you found it to postpone urination?Urgency *0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half time4 = More than half the time5 = Almost alwaysWeak steam*How often have you had a weak urinary stream?Weak steam *0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half time4 = More than half the time5 = Almost alwaysStraining*How often have you had to push or strain to begin urination?Straining *0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half time4 = More than half the time5 = Almost alwaysNocturia*How many times did you most typically get up to urinate from the time you webt to bed until the time you got up in the morning?Nocturia *0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half time4 = More than half the time5 = Almost alwaysNocturia*How many times did you most typically get up to urinate from the time you webt to bed until the time you got up in the morning?Nocturia *0 = No1 = 1 time2 = 2 times3 = 3 times4 = 4 times5 = 5 timesGynecological HistoryDate of last menstrual period:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Bleeding 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 asthma?* Yes No Do you experience shortness of breath?* Yes No Are you currently using a BiPAP machine?* 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 erectile dysfunction?* Yes No How many times?* How did it work?* Have you had an erection for more 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