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Are You a Candidate for Weight Loss Surgery?
Take our 60 Second Assessment to Find Out.
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Assessment - Website
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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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9
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: Convert Height to Total Inches
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Hidden: BMI Calculator
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What is your height and weight?
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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?
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Select one from below.
Can I afford it?
Is surgery right for me?
Will I keep the weight off long-term?
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Which payment option describes you best?
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Select one from below.
Self-Pay / Financing
Private Insurance
Medicare
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15
Have you decided which treatment is right for you?
Select one from below. If you are not sure yet, that is perfectly fine. Just select "Not Sure Yet"
Not Sure Yet
Gastric Bypass
Sleeve Gastrectomy
Gastric Band
Revision
Duodenal Switch
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16
Where are you in your Weight Loss Surgery decision process?
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Step 1. Researching
Step 2. Evaluating Treatments
Step 3. Choosing my Doctor
Step 4. Ready to Book a Consult
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Thanks! Where can we send your results?
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Enter your information below to receive your Personalized Results. You will also receive an Email Course about your weight loss options from Beltre Bariatrics | Orlando Center for Metabolic and Obesity Surgery. 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. By providing your cell phone number you agree to receive calls and texts to that number from Beltre Bariatrics.
First Name
Last Name
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Phone
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Email
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Phone
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First Name
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Last Name
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English
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Assessment - Date of Submission
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