Inquiry Form – Braziltourism

What type of treatment do you wish to undergo?

Dental

Aesthetic (Minor procedures, wrinkles, and minor cosmetic surgery)

Insertion of breast or penile implants

Spa and relaxation

Do you have up-to-date exams and x-rays?

Yes

No

Do you have any pre-existing conditions?

Yes

No

Do you have any allergies?

Yes

No

Are you taking any medication?

Yes

No

Do you wish to take sightseeing tours during or after treatment

Yes

No

Will you be traveling to Brazil with someone?

Yes

No