Patient Form

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Personal Information

Patient Name

Medical History

Medical History
Medical History
Do you regularly drink over 3 cups of coffe per day?
Do you regularly drink alcohol or beer?

Smokers Must Read

My Medical Vacations will not accept patients who smoke. Generally speaking, smokers have poor blood circulation, which is extremely dangerous in terms of the healing process. If you are a smoker, you must completely cease from smoking at least four weeks before surgery or else you are at high risk for getting a necrosis.

According to the American Society of Aesthetics and Plastic Surgery (ASAPS), a necrosis occurs when, due to poor blood circulation, oxygen is not adequately provided to the traumatized areas post-surgery. This often causes the affected of skin to literally die, turn black and fall off. I know this is very graphic, but many smokers do not take this seriously, and it is a very serious situation. After about one year, the skin regenerates itself, leaving an unsightly scar.

In the past, there have been patients who were smokers who told My Medical Vacations Surgical team they were not. Needless to say, we believe whatever oue patients tell us. Therefore, a misrepresentation regarding smoking puts the patient at great risk. If something should happen to the patient as a result of that misrepresentation, it is extremely disturbing to our team.

Your safety and excellent results are of paramount importance to us. Shouldn’t it be of paramount importance to you, too? It really isn’t worth putting yourself through an unnecessary risk for the sake of plastic surgery, is it? So, smokers beware and understand that you've been forewarned!

Accepted smokers' risk
Will you agree to stop smoking one month prior to receiving surgery?


Do you take herbal suplements?

Familiy History

Have blood relatives had?
Have blood relatives had?

Serious illnesses or injuries


Blood related

Are you Anemic or do you have the suspicion of being anemic?
Have you suffered excess bleeding (menorrhagia) during the last 12 months?

Blood Type

Previous Surgeries

Have you had any complications during previous surgeries?


Is there a chance you may be pregnant?
Regular Menses?
Did you breastfeed?
Breast Cancer
Breast Biopsy
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