TLC - Online Assessment 2.0

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I am...

Male

Female

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Do you struggle to maintain a healthy weight using only diet and exercise?

Yes

No

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Do you suffer from any of these common health issues?Select all that apply. Then select "Next."

Heartburn / Acid Reflux

High Blood Pressure

Sleep Apnea

Diabetes

Joint/Bone Issues

Depression

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Hidden field: if heartburn is selected, pass in value of 1

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Hidden field: Pass in Heartburn if value is 1 from previous question

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Hidden: Convert Height to Total Inches

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Hidden: BMI Calculator

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What is your height and weight?* This field is required.Enter your height and weight below.

Weight (lbs)

Height (ft)

Height (in)

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What is your biggest challenge or question right now?* This field is required.Select one from below.

Cost: Can I afford it?

Safety: What are the risks?

Life After Surgery: Will I keep the weight off?

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Have you decided which treatment is right for you?* This field is required.Select one from below. If you are not sure yet, that is perfectly fine. Just select "Not Sure Yet"

Not Sure Yet

Gastric Sleeve

Gastric Bypass

Duodenal Switch

Medically Supervised Weight Loss Program

Gastric Balloon

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Where are you in your Weight Loss Surgery decision process?* This field is required.

Step 1. Researching

Step 2. Evaluating Treatments

Step 3. Choosing my Doctor

Step 4. Ready to Book a Consult

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Do you want a Free Insurance Check, to find out if your insurance covers Weight Loss Surgery?* This field is required.Our insurance specialists would be happy to contact your insurance provider for you, and let you know whether or not they cover weight loss surgery.

I want a Free Insurance Check

No thanks

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Great! Where can we send your Results?

Enter your information on the next screen to receive your Personalized Results. You will also receive an Email Course about your weight loss options from the team at Texas Laparoscopic Consultants in Houston, Texas. 🔒We keep your information safe and private.

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Ok, no problem. Where can we send the Results of this Assessment?

Enter your information on the next screen to receive your Personalized Results. You will also receive an Email Course about your weight loss options from the team at Texas Laparoscopic Consultants. We keep your information safe and private🔒. This Assessment is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment.

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First Name* This field is required.

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Last Name* This field is required.

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Email* This field is required.

example@example.com

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Phone* This field is required.

Type your number with no parentheses or dashes

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Today's Date

Date