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 confidential, we 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.
* = required
