NEW PATIENT REGISTRATION FORMPersonal Information New patients at Plastic Surgery Tijuana, are required to complete the New Patient Form, and Patient's Medical History.Name *Phone *Email *Gender *Marital Status Age *Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEmergency Contact Information In case of an emergency, please provide us with the name, relationship, and phone number of someone we can contact.Contact's Name *Relationship *Contact's Phone *Personal Habits We need to know about your own personal habits; some might be long standing, while others might be more recently acquired.Do you smoke regularly? *YesNoDo you drink coffee regularly ? *YesNoDo you drink alcohol regularly? *YesNoMedical Information Tell us about any medical conditions you suffer or have suffered.AIDS or HIV YesNoCongenital Heart YesNoLeukemia YesNoArthritis YesNoDiabetes YesNoMigraine YesNoAsthma YesNoEpilepsy YesNoNervous Breakdown YesNoBack Problems YesNoGoiter YesNoPneumonia YesNoBladder Infection YesNoHay Fever YesNoRheumatic Heart YesNoBleeding Tendency YesNoHeart Attack YesNoStomach Ulcers YesNoBronchitis YesNoHepatitis YesNoStroke YesNoCancer YesNoHigh Blood Pressure YesNoTonsilitis YesNoColitis YesNoKidney Disease YesNoTuberculosis YesNoMedications Are you presently taken any of the following medications?Antibiotics YesNoCortisone YesNoInsulin or Diabetic Pills YesNoAspirin, Bufferin, Anacin YesNoCough Medicine YesNoIron or Poor Blood Medication YesNoThyroid Medicine YesNoSleeping Pills YesNoBarbiturates YesNoDigitalis YesNoLaxatives YesNoTranquilizers YesNoBirth Control Pills YesNoDilatin YesNoMedicine for Arthritis YesNoWater Pills YesNoBlood Pressure Pills YesNoHeadache Pills YesNoPhenobartital YesNoWeight Reducing Pills YesNoBlood Thinning Pills YesNoHormones YesNoShots YesNoOther Drugs Not Listed YesNo VerificationType the following characters: 32 *I authorize the release of any and all medical information to all physicians involved in my care and treatment.This box is for spam protection - <strong>please leave it blank</strong>: DR. RAFAEL CAMBEROS Online Consultation
