MEDICAL ANALYSIS

In just a few steps we will provide you a personalized solution to restore your trust.

STEP 1 OF 12

CHOOSE YOUR GENDER:

STEP 2 OF 12

What areas of your body are you most concerned?:

SELECT AREAS: Eyes
Nose
Cuello
Breast
Breast Lateral
Upper abdomen
Lower abdomen
Flanks
Hips
Outer Thighs
Thighs front
Inner Thighs
Lower Leg Front
Ankles
Upper Back
Mid Back
Lower Back
Buttocks Upper
Buttocks Lower
Thighs Back
Lower Leg Back
Other areas not indicated

STEP 2 OF 12

What areas of your body are you most concerned?:

SELECT AREAS: Eyes
Nose
Cuello
Chest area
Lateral sinus area
Upper abdomen
Lower abdomen
Flanks
Hips
Outer Thighs
Thighs front
Inner Thighs
Lower Leg Front
Ankles
Upper Back
Mid Back
Lower Back
Buttocks Upper
Buttocks Lower
Thighs Back
Lower Leg Back
Other areas not indicated

STEP 3 OF 12

Which of the following figures best reflects your body shape?:

SELECT YOUR BODY SHAPE: 01
02
03
04
05
06
07

STEP 3 OF 12

Which of the following figures best reflects your body shape?:

SELECT YOUR BODY SHAPE: 01
02
03
04
05

STEP 4 OF 12

MEDICAL HISTORY

Do you suffer from any of the following conditions? High blood pressure
Heart disease / heart attack
Heart valve disorder (s), murmur
Chest pains, Angina
Irregular heartbeat
Shortness of breath
Asthma
Sleep apnea, snoring
Blood clots (DVT)
Coagulation disorders, hemophilia
Easy bruising / excessive bleeding
Diabetes
Kidney or liver problems
Anemia
Blood clots (DVT)
Reflux - Hiatal Hernia
Herpes, Fever Ampoules
Depression
Mental Disorders
Dry eyes
Glaucoma
Fainting
ICTUS, TIA's

Please detail the ones listed above or any other medical conditions that are not listed.

STEP 5 OF 12

MEDICAL HISTORY

List all medications, supplements, vitamins, or natural treatments you are using regularly:

Do you suffer from allergies or illnesses? (List all medications, products, or other agents to which you have had an allergic reaction):

Do you have any blood related problems such as HIV, hepatitis B or easy bruising etc. (Specify ...):

All previous hospitalizations and / or operations:

Do you use aspirin or a blood thinner? (Specify ...):

STEP 6 OF 12

MEDICAL HISTORY

Do you suffer from wounds that take longer to heal?

Do you suffer from keloid scars?

Have you or any member of your family had an unfavorable reaction to anesthesia?

If yes, please specify ....

List any medical conditions that affect your family: blood clots, bleeding disorders, breast cancer.

Additional explanation:

STEP 7 OF 12

MEDICAL HISTORY

Latest mammogram (date)

Latest EKG (date)

Number of pregnancies:

Ages of children:

Any more planned?

STEP 8 OF 12

MEDICAL HISTORY

Do you drink alcohol?

If so, how many drinks per week?

Any other drugs?

Do you smoke?

If so, how many packs per day?

How many years?

If you quit, when?

STEP 9 OF 12

PERSONAL INFORMATION

INDICATE YOUR AGE:*

INDICATE YOUR HEIGHT:*

INDICATE YOUR WEIGHT:*

How much weight loss? or gain?

What type of blood do you have?

STEP 10 OF 12

CONTACT DETAILS

NAME:*

PHONE:*

EMAIL:*

CITY:*

STEP 11 OF 12

REFERENCE CODE

If you have previously been in contact with our team or have visited one of our establishments, they may have given you a reference code. If you don't have any, go to the next step please.

Specify reference code:

LAST STEP

How do you prefer to be contacted?

Choose based on your preferences. Telephone Call
Video call
Whatsapp
Email

Indicate in which time slot you want to be contacted:

REGENE - Health Care

MEDICAL ANALYSIS

In just a few steps we will provide you a personalized solution to restore your trust.

STEP 1 OF 12

STEP 2 OF 12

STEP 2 OF 12

STEP 3 OF 12

STEP 3 OF 12

STEP 4 OF 12

STEP 5 OF 12

STEP 6 OF 12

STEP 7 OF 12

STEP 8 OF 12

STEP 9 OF 12

STEP 10 OF 12

STEP 11 OF 12

LAST STEP

FACE SURGERY

BREAST SURGERY

BODY SURGERY

BOTULINUM A & FILLER

INFO FRANCE

INFO FRANCE

INFO SPAIN

INFO SPAIN

INFO ITALY

INFO ITALY