drjlmejiasform

Name

Phone Number

Birthdate

Country of Residence

Weight (Lbs).

Height (ft).

Do you have history of Hep B or C?

Do you have or suffered from diabetes?

Do You Suffer From Any Illnesess or Conditions?

Do You Snoring?

Smoke, how many a day? Hooka?

Do you have or did you suffer from lupus?

Have You Had Symptoms of Any type of Breathing?

Have you had children? How many? Caesarean or Natural Delivery?

Please List All Prior Surgeries And Dates

Have you had falsemia?

Have you had a blood transfer in the last 6 or 12 months?

Procedure to be Performed

Please List All Prior Surgeries And Dates

Select files

You can send a document (.pdf) here.