Section 1 of 2
Evaluación Inicial de tu Caso
Completa este formulario para que el Dr. Carlos Gil Larocca pueda revisar tu caso de manera personalizada.
La información que compartas será tratada con confidencialidad y utilizada únicamente para conocer tu motivo de consulta, evaluar tus fotografías y comprender mejor tus necesidades estéticas o funcionales.
Este formulario no sustituye una consulta médica presencial, pero permite obtener una primera impresión del caso.
Por favor, completa los datos solicitados y adjunta las fotografías siguiendo las indicaciones de cada vista.
Importante: Si usas la cámara del móvil, asegúrate de utilizar la cámara trasera en lugar de la frontal para evitar el efecto espejo.
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Nombre y Apellido
Nombre y Apellido
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Fecha de nacimiento
Fecha de nacimiento
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Cédula
Cédula
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Teléfono
Teléfono
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Ciudad
Ciudad
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Section 2 of 2
Historial del Paciente
Motivo de consulta
Motivo de consulta
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¿Te has practicado alguna cirugía nasal previamente?
¿Te has practicado alguna cirugía nasal previamente?
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Si es "Si" especifique e incluya la fecha
Si es "Si" especifique e incluya la fecha
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¿Has sufrido alguna fractura nasal?
¿Has sufrido alguna fractura nasal?
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¿Te has realizado algún tratamiento de rinomodelación?
¿Te has realizado algún tratamiento de rinomodelación?
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¿Respiras bien por la nariz?
¿Respiras bien por la nariz?
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Si es "No" especifique
Si es "No" especifique
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Describa brevemente los objetivos que pretende alcanzar con la cirugía
Describa brevemente los objetivos que pretende alcanzar con la cirugía
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Sube las fotos según indicaciones de la imagen
Sube las fotos según indicaciones de la imagen
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Vista frontal
Sube Tu Foto
Sube Tu Foto
Vista frontal
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Sube Tu Foto
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Vista Perfil Derecho
Sube Tu Foto
Sube Tu Foto
Vista Perfil Derecho
Sube Tu Foto
Sube Tu Foto
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Vista Perfil Izquierdo
Sube Tu Foto
Sube Tu Foto
Vista Perfil Izquierdo
Sube Tu Foto
Sube Tu Foto
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Sube las fotos según indicaciones de la imagen
Sube las fotos según indicaciones de la imagen
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Vista Oblicua Derecha
Sube Tu Foto
Sube Tu Foto
Vista Oblicua Derecha
Sube Tu Foto
Sube Tu Foto
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Vista basal
Sube Tu Foto
Sube Tu Foto
Vista basal
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Sube Tu Foto
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Vista Oblicua Izquierda
Sube Tu Foto
Sube Tu Foto
Vista Oblicua Izquierda
Sube Tu Foto
Sube Tu Foto
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