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Bariatric Surgery Request Form
Congratulations on taking the first step towards being healthier. We can’t wait to support you through this process but first we need to gather some information, ok?
21
Questions
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1
Name
First Name
Last Name
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2
Phone Number
Must be connected to Whatsapp
Please enter a valid phone number.
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3
Email
example@example.com
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4
Age
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5
Current Weight
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6
Height
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7
Gender
Female
Male
Non-binary
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8
Date of Birth
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9
Do you currently have or have a history of Asthma ?
YES
NO
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10
Do you currently have or have a history of Diabetes?
YES
NO
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11
Do you currently have or have a history of Hypertension?
YES
NO
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12
Have you had a previous Bariatric procedure?
YES
NO
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13
Do you smoke?
This includes hookah, vape, marijuana, etc
YES
NO
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14
Do you suffer from Anxiety?
YES
NO
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15
Do you currently suffer from any other health condition?
YES
NO
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16
Known Allergies?
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17
Have you had any plastic surgery procedures done? If so, please tell us when and which procedures.
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18
Do you use Aspirin or Warfarin?
YES
NO
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19
Desired Procedure Date
When do you want to come?
-
Date
Year
Month
Day
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20
File Upload
Please upload a front facing photo in clothing
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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21
File Upload
Please upload a side facing photo in clothing
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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