This Digital Photographic Consultation form is divided into 4 Steps:

Step 1: Personal Information ► You are here
Step 2: Sending photos and previous reports
Step 3: Confirmation and Payment
Step 4: Await Clinic Notification (maximum 10 business days -Monday to Friday.)

We would appreciate it if you answered the following questions with the utmost sincerity and detail, as this will be the information that determines Dr. Guilarte’s subsequent diagnosis and report. All fields are mandatory, so it is necessary to fill in all fields, even when the answer is ‘no’ or ‘none’; you should write this in the form.”

➊-②-③-④ Digital Photographic Consultation – Queiloplasty

Contact details:

Name*

First Surname *

Second Surname *

ID Number / PASSPORT * (Without hyphens)

Date of Birth (dd/mm/yyyy) *

Nationality

Email *

Contact Phone Number *

Profession *

Address *

City *

Postal Code *

Province *

Select consultation type *

Note: The Simulation and Quote Consultation does not include the video diagnosis.

Medical History:

Do you have or have you had any physical or psychological pathology and/or illness?

Do you have any allergies?

Do you take any type of medication?

Have you had any previous surgical procedures? (Other than silicone removal) *

Information about your face:

Do you have any pathology in the area? *

Have you had previous surgical intervention in that area? *

Please provide the date:

After the initial procedure, have you undergone any additional touch-ups? *

How many?

When?

Where? *
In a clinicIn a hospitalNo surgery or subsequent touch-up has been performed on me

Have you had any injections with hyaluronic acid or other types of fillers in the area? *

Please specify when:

What do you not like about your nose? *

What would you like to change or improve? *

When would you like to proceed with the procedure? Indicate approximate months and year. (The procedure's timing is dependent on the operating room schedule.) *

How did you hear about us? *

Instagram username:
@

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