Patient Eligibility Questionnaire This decision could change your life !

  • This form has the soul purpose of learning the basic information to determine if you qualify for a weight loss procedure.
  • There is no cost or obligation and you will receive an email with information about the procedure, our available packages and pricing as well as date availability. You will receive one text message to confirm that you have received the information we send via email.
  • The information submitted by you is privileged and confidentialwe do not distribute or share this information with third parties.
  • Revision surgery patients please describe the previous procedure at the "other" section, the type of original surgery, the date, start and current weight and if the original procedure was open (not via laparoscopy) please let us know.
  • If you are undergoing  treatment for any condition please describe it and let us know what medication you are taking, the dosage and frequency.
  • Financing is available, if you need Information please let us know at the "other: section.
  • By filling this form you agree to receive an email with information requested and a text message, should you choose not to receive emails and text messages please let us know your preference. You can also reply to our text the word "STOP" and we will not text you again. We do not send automated text messages.

* = required

Body Mass Index

Obesity Related Problems




Bone Problems


Sleep Disorders

Physical Condition

Digestive System

Heart and Circulatory System

Respiratory Problems

Compulsive Eating

Low Expectations


Gastro Esophageal Reflux

Hiatal Hernia

Dr. Verboonen

Dr. Sergio Verboonen

Dr. Verboonen has been providing life-changing bariatric surgery for a diverse range of patients since 1995. He and his team have performed thousands of bariatric procedures at our Tijuana, Mexico, practice. We are proud to be affiliated with:

  • International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)
  • Colegio Mexicano de Cirugía para la Obesidad y Enfermedades Metabólicas, A.C.
  • American Society for Metabolic & Bariatric Surgery

Fill out our form to get started.

For more information about our services, contact our practice online or call (619) 629-0222

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