Business Hours

Patients can make appointments by calling our office directly:
Phone: (011)(506) 2522-1501 or (011)(506) 2233-0152
Fax: (011)(506) 2253-2530.
International: (424) 234-5050
(when calling from the US and Canada)
email: info@plasticacostarica.com

Our office is open Monday thru Friday.

Request Information
Required fields = *

First Name:
A value is required. *
Last Name:
A value is required. *
Home Telephone:
A value is required. *
Office Telephone:
A value is required. *
Address Line:
A value is required. *
City:
A value is required. *
State:
A value is required. *
Country:
*
Zip Code:
A value is required. *
Occupation:
Gender
*
Marital Status :
*
Age:
A value is required.Invalid format. *
   
BMI Calculator for Adults using english:
Height: A value is required.Invalid format. feet *
A value is required.Invalid format.  inch(es) *
Weight:
A value is required.Invalid format. pounds *
   
Email Address:
A value is required.Invalid format. *
Are you currently taking any medications or non prescription drugs or herbs? (Please describe (name and dosage) )
Do you smoke? Frequency?
Do you drink? Frequency?
Do you exercise? Frequency?
Have you taken any cortisone on the past year? If positive Please specify
Are you allergic to any drugs?
Do you suffer any disease like diabetes, high blood pressure, etc? Please specify
Do you have any psychiatric problems?
Do you have a spiritual preference?
(For example please indicate here if you are a Jehovah's Witness.)
Have you ever had any surgeries? Describe procedures and dates.
Have you ever had any reaction to any type of anesthesia?

Please tell us which procedure(s) you are inquiring about. Hold the control key down while selecting to highlight multiple procedures.

Please describe any other important details you would like to add*
A value is required.