MEDICAL HISTORY FORM - Endobariatric

Please note:

- Dr. Alvarez will review this information to see if you are eligible for sleeve surgery.

- We are located in Piedras Negras, Mexico (8 blocks from the U.S.)

- Our Regular All-inclusive price for the Gastric Sleeve is $8,900.00 USD.

LIMITED TIME OFFER: We are currently offering 10 spots/month at a discounted price of $4,999 USD.

Personal Information

Please make sure to complete required fields * 

Please be sure we have your complete and accurate address so we can mail you surgery information if qualified and decide to move forward for surgery with Dr. Alvarez.

Contact Information

Medical History

Do you CURRENTLY have any of the following conditions? (Please select the appropriate option)

Have you EVER had any of the following conditions or diseases? (Please check the appropriate blocks)

General Medical History (Please type your answer or click in the appropriate blocks)

Our patients must fully understand their financial obligations along with our payment, scheduling, and cancellation policies before undergoing surgery with Endobariatric/Endohospital. These policies are documented on the medical history form & require the patient's signature for consent.

When you schedule surgery, we must reserve the time in the operating and hotel rooms at Endohospital/Endohotel, EndoLab staff, tests, surgical nurses, technicians, anesthesiologists, and staff to be available. We are still held accountable if this time isn't used; also, we must turn down other patients who could have wanted surgery on the day and time we have reserved for you. We understand that a situation that could force you to postpone your surgery may arise. However, please understand that such changes affect not only your surgeon but other patients as well. Dr. Alvarez's time, as well as that of the operating room staff, disposable material contemplated for your surgery, your private designated hospital suite, and hotel accommodations at our hospital, is a precious commodity and requires your courtesy and concern. Please don't hesitate to contact your patient coordinator if you have any questions about these policies.

• The surgery quote will be honored for 3 months from the date of filling out your medical history form.
• $1,000 of your payment is a non-refundable and non-transferable deposit. Valid for 6 months. No Exceptions.
• All Cash Price Promo Payments must be paid in full upon scheduling surgery.
• All Credit/Debit Card or Financing Payments must pay a $1,000 deposit and the remaining balance no later than Twenty-one (21) days before surgery, or you must reschedule for a later date. All patients are required to have a zero balance before traveling to Mexico. If payment is not received, your surgery will be canceled to allow another patient to use the surgery time. Any costs incurred by the patient due to late payment and processing times, such as hotels, flight cancellations, or rescheduling, will be the patient's sole responsibility.
• Payment for all procedures is the responsibility of the patient. If someone other than the patient makes a payment for the procedure, they will also need to sign this policy.
• You are responsible for any fees your bank, credit card, or finance company charges.
• If canceling or postponing the surgery, the balance will be governed by our cancellation policy stated below.

• If you cancel or reschedule your surgery more than 21 days before the original surgery date, we will reschedule your surgery one time. The deposit can be used within 6 months of the initially scheduled surgery date.
• If you cancel or reschedule surgery 8-20 days before your surgery, you are entitled to a refund of 50% of your surgery fee.
• You will forfeit your entire surgery fee if you must cancel your surgery 7 days or less before surgery.
• If you need to reschedule your surgery, please do so as soon as possible since the operating room has been reserved for you.
• Please remember that if you discontinue care before your surgery is complete, your deposit is non-refundable and non-transferable.
• All cancellations must be received by Endobariatric in writing, via email, or fax. Please see your coordinator for the cancelation form.
• If you need to cancel or reschedule due to any travel delays due to your flight, it is governed by our policy, as stated. We always ask patients to be aware of possible delays due to weather or time frames so that they arrive on time for pick-up by our driver. We have the cooperate rate locked in at the hotel for those who need to arrive a day early for safety measures.
• If surgery is canceled or postponed due to medical conditions discovered during the pre-operative time, life-threatening emergencies, or if it is determined that surgery can not proceed due to safety reasons, there will be exceptions made due to these circumstances once the hospital administration reviews the proper documentation.
• There will be no funds held back if surgery is rescheduled/canceled by Endohospital.

I, the patient, have discussed payment options and agreed upon a payment plan with Endobariatric SC. I understand my deposit of $1,000.00 is to guarantee the listed surgery date for my VSG surgery. When my surgery is scheduled, Endobariatric has arranged for the operating room, Dr. Alvarez, the anesthesia team, and surgical staff to be at my operation. These team members are confirmed for my surgery date three weeks before the scheduled time. I understand and agree to the following terms by signing this form.