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Consulta Virtual

Online Evaluation

Are you filling out this form for a virtual or in-person consult with Dr. Lopez?*
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Name*
First Last
Sex*
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Email*
Mobile*
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Procedures you are interested in*
- Abdominoplasty
- Blepharoplasty
- Breast Augmentation
- Breast Reduction
- Breast Reconstruction
- Butt Augmentation
- Butt Lift
- Face
- Facetite / Morpheus8 / Bodytite
- Gynecomastia
- Liposuction and Liposculpture
- Mastopexy
- Minimally Invasive
- Otoplasty
- Post-bariatric Surgery
- Rhinoplasty
- Ritidoplasty
- Thigh Lift
- Vaser® Liposuction
- Other
Please specify the other procedures you are interested in*
Age*
Height*
Current Weight (lbs)*
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BMI*
Are you taking any regular medications?*
- Yes
- No
Please specify the medications you take regularly*
Do you have any health problems?*
- Yes
- No
Do you have any of the following health conditions?*
- Asma
- High Blood Pressure
- Thyroid Disease or Disorder
- Diabetes
- Other
Please describe your health condition(s)*
Have you had previous surgeries?*
- Yes
- No
Please specify your previous surgeries*
Do you have children?*
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How was your childbirth?*
Do you have alergies?*
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What are you alergic to?*
Do you smoke?*
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How many cigarettes a day do you smoke?*
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Plastic Surgery Member of the International Society of Aesthetic Plastic Surgery, ISAPS. Dominican Society of Aesthetic and Reconstructive Plastic Surgery, SODOCIPRE. Ibero-Latin American Federation of Plastic and Reconstructive Surgery, FILACAP. Brazilian Society of Plastic Surgery SBCP. Dominican Association of Health Tourism ADTS.

Centro de Rejuvenecimiento y Cirugía Plástica Avanzada
Av. Gustavo Mejía Ricart
Esq. Federico Geraldino, Piantini
Plaza Jenika, 3er Piso, Suite 301
Santo Domingo

+1 809-692-4071

info@drlopezcollado.com

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