Luxora Aesthetics: Beleza e Saúde Exclusivas

Pre-Consultation Medical Form for International Patients

Aesthetic and Dental Procedures in Brazil

This questionnaire aims to collect initial health and personal information from international patients so that the medical team can perform a safe preliminary evaluation before planning any procedures.

Full name:*

Date of birth

Nationality

Passport number

Country of residence

International phone number (with country code*

Email*

Do you have any chronic diseases?

Yes

No

If yes, which ones?

Do you take any continuous medications?

Yes

No

If yes, list them

Do you have any allergies to medications or anesthetics?

Yes

No

If yes, which

Have you had any previous surgeries?

Yes

No

If yes, which and when?

Do you have a history of surgical complications?

Yes

No

Do you have diabetes?

Yes

No

Do you have hypertension?

Yes

No

Do you have heart problems?

Yes

No

Do you have blood clotting disorders?

Yes

No

Are you pregnant or suspect pregnancy?

Yes

No

Which aesthetic procedure are you interested in?

Have you undergone aesthetic procedures before?

Yes

No

If yes, which?

Have you had dermal fillers or botulinum toxin treatments?

Yes

No

Have you had plastic surgery before?

Yes

No

Do you have a tendency for keloids or difficult scarring?

Yes

No

Are you currently undergoing any dermatological treatment

Yes

No

Do you smoke?

Yes

No

Do you consume alcoholic beverages?

Yes

No

Do you practice physical activities regularly?

Yes

No

Do you have any dietary restrictions?

Do you intend to perform additional procedures besides those mentioned?

Yes

No

Would you like to include a recovery spa package?

Yes

No

Would you like to include a tourism package during your stay?

Yes

No

Patient Declaration - I declare that the information provided is accurate and I understand that this is a preliminary evaluation. Additional exams may be required before any procedures are performed.*

I declare

Form for Aesthetic Treatment

Documents and Photos Submission

For the initial medical evaluation, please provide:

Face photos (front and profile) – for aesthetic procedures
Photos of the treatment area (when applicable)
Recent dental X-rays or exams (if available)
Relevant medical reports

Documents and Photos Submission

For the initial medical evaluation, please provide:

Face photos (front and profile) – for aesthetic procedures
Photos of the treatment area (when applicable)
Recent dental X-rays or exams (if available)
Relevant medical reports

Form for Dental Treatment

Pre-Consultation Medical Form for International Patients

Aesthetic and Dental Procedures in Brazil

Documents and Photos Submission

Documents and Photos Submission

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