Home
About
Services
Contact

Home
About
Services
Contact

Contact us

Feel free to contact us with any questions or concerns. You can use the form on our website or email us directly. We appreciate your interest and look forward to hearing from you.

Email

Info.pincelprincess@gmail.com

Phone

(829) 241-7859

(849) 505-7859

Address

Jose J Perez # 105 Consultorio 5-10
Santo Domingo, Distrito Nacional, 10201 Dominican Republic

Social media

Full Name*

Your email*

Date of Birth*

Age*

Nationality*

City and Country of Residence*

How did you hear about us?*

Height*

Weight*

Do you exercise regularly?*

Yes

Do you currently smoke or use any recreational substances? (Includes cigarettes, hookah, marijuana, tobacco, or others) If Yes, please specify the type and frequency*

Number of children*

Delivery method(s): (Specify if Natural/Vaginal or Cesarean section)

Have you had any pregnancy losses (miscarriages or stillbirths)?*

Yes

Date of your last pregnancy*

Do you have any known allergies to medications or foods? If Yes, please list*

Do you take any medications (prescribed or over-the-counter)? If Yes, please list all*

Do you currently use any contraceptive method? If Yes, please specify the type*

Have you ever tested positive for HIV?*

Yes

Do you have a history of Hepatitis A, B, or C? If Yes, please specify*

Do you have a history of or currently suffer from any of the following conditions? (Please check all that apply)*

Asthma

Diabetes

High Blood Pressure (Hypertension)

Thyroid Condition

Lung Disease

Sadness or Depression

Arthritis or Bone Pain

Liver Disease

Kidney (Renal) Disease

Lupus or other Immune Disease

Sickle Cell Trait/Anemia

Previous Thromboembolism (blood clot)

Rheumatic Disease

Please list all previous surgeries or major medical visits you have had in your lifetime, including the approximate date and reason for the procedure/visit*

Procedure(s) you wish to have performed*

Preferred/Probable Date for Surgery*

drpincel

Pedro Chalas Drpincel

Dr. Pedro Chalas

Reach out for appointments or questions

Contact us

info@drpincel.net

+1 (829) 241-7859

Your Full Name

Terms and Conditions

+1 (849) 505-7859