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Dr. Rodrigo Araya any questions before filling out our registration form.

Patient First and Last Name:
Age:
Sex:
Race:
Height:
Weight:  
  Current Weight: lbs.
  Maximum weight last 3 years: lbs.
  Minimum Adult Weight: lbs.
Marital Status:
Single Married Divorced
Occupation:
Former Occupation:
Special Type of Work you do:
Hobbies / Sports:

Home Tel:
Cel Tel:
Address
City
State
Country Zip:
E-mail:
Reffered by:

Procedures interested in:

Head / Face

Asian Eyes - Blepharoplasty
BOTOX® Cosmetic
Chemical Peel
Dermabrasion
Eyelid Surgery (Blepharoplasty)
Fat Injections
Hair Transplant & Restoration
Facelift
Forehead Lift
Lip Augmentation		 Laser Skin Resurfacing
Lower Eyelid Surgery (Blepharoplasty)
Nose Surgery (Rhinoplasty)
Scalp Flaps/Scalp Lift
Cheek Augmentation/Implants
Chin Augmentation/Implants
Ear Surgery (Otoplasty)
Neck Liposuction
Scar Revision/Scar Repair
Upper Eyelid Surgery (Blepharoplasty)
Skin Injection Treatments

Breast

Breast Asymmetry
Breast Reconstruction
Gynecomastia (Male Breast Reduction )
Breast Augmentation		 Breast Lift
Breast Reduction
Inverted Nipple Repair
Mole Removal
Scar Revision/Scar Repair

Arms

Arm Lifts/Brachioplasty
Hand Surgery
Arm Liposuction

Abdomen

Abdominal Liposculpture (Liposuction)
Body Lift
Mole Removal
Abdominoplasty (Tummy Tuck)

Buttocks/Groin

Butt Implants (Buttock Augmentation)
Labiaplasty
Buttock Liposculpture/Liposuction
Phalloplasty (Penile Enlargement)

Legs

Thigh Liposculpture

Payment method:
Medical Information
Please fill out this medical questionaire to the best of your knowledge. It will help us make better desicions regarding your surgical procedure.
*Do you have any heart problems?   *Do you have alcohol problems?  
*Do you suffer from asthma?   *Do you have high blood pressure?
*Do you have coagulation disorders? *Do you have an ulcer?
*Do you have diabetes? *Do you smoke?
List any medications you take regularly:
Please list your known allergies:
List the major, if any, surgeries you have had: 

Additional Commentary
   

PAYMENT INFORMATION:

  • I accept cash, or cashier’s checks, but no Credit Cards.  All surgeries must be paid in full a day prior the procedure
  • The Hospital accepts accepts cash, cashier´s checks, traveler´s checks and VISA, MASTERCARD and AMERICAN EXPRESS Credit Cards.
  • The Recovery Homes usually accept cash, cashier´s checks or traveler´s checks, but no Credit Cards. Please verify the Recovery Home payment information.

 

 

 

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For more information or comments, please fill out our Information Request Form
or email us to: info@draraya.com | Phone: (506) 2208-8211 / 2208-8261