Plastic & Reconstructive Surgery Health Questionaire
In order to provide you with a formal and accurate plastic and reconstructive surgery quote, an evaluation of your case is required. Please complete the following information so Dr. Galvez and our medical team can better assess your case.

Please Note: When you submit your questionnaire, you can rest assured that your information is protected by one of the most trusted names in internet security and that all information submitted via our web forms is transmitted privately and safely.
Which procedure(s) you are interested in / areas you would like assessed? *

What date would you like to schedule surgery?

Contact Information

What is your first name? *

{{answer_67708042}}, nice to meet you.
What's your last name? *


Home number or primary phone number with area code
Cell phone

Mobile number with area code
Street Address



Zip Code

Do You Have a Passport/Passport Card?

Date of Birth

Will you have a companion?

Info about your stay:

Do you require a recovery stay? If yes, how many nights?

Average stay is between 5 and 12 nights
Do you require one or two beds for your recovery stay?

Do you and your guest have a passport and/or passport card?

(if bringing one)
Medical History:

Are you a Weight Loss Patient (WLP)?


Current Weight

Do you smoke?

Do you drink alcohol?

Please list all allergies

List all medications you are currently taking, including vitamins

Please list any previous surgeries and their dates

Other information regarding your medical history

If you would like to have a direct phone consultation with Dr. Galvez, please list the best day and time to call you, along with your location/time zone:


Without clothes/underwear, please take 100% visible pictures of the areas you would like to assess.
Frontal Pictures

Back Pictures

Lateral Pictures

Bending forward – photo should be taken from the side
Oblique Pictures

Left and right half profile of the area to assess
Flex Position Pictures

With your arms lifted.

A) From the neck to your knees - if interested in body procedures, or

B) From the top of your head to your shoulders - if interested in facial procedures.
Last question, {{answer_67708042}}! How did you hear about Dr. Galvez and BariatricPal Hospital MX? *

Please be as specific as possible!
{{answer_67708042}}, thank you for completing your plastic surgery questionnaire for {{answer_67695017}}! Dr. Galvez and his medical team will review your information and we will reach out to you within 24 hours. 

If you have any questions, please feel free to contact us Toll-Freee at (844) 957-3325 or via email .

We look forward to seeing you soon!