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Find out if you are a Candidate for Weight Loss Surgery
1
Have you struggled with keeping weight off with diet and exercise?
YES
NO
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2
What is your current height and weight?
Enter your height and weight below.
Height (ft)
Height (in)
Weight (lbs)
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3
Which payment option describes you best?
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Cash
Financing
Private Insurance
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4
Do you suffer from:
Select all that apply.
High Blood Pressure
Heartburn / Acid Reflux
Diabetes
Obstructive Sleep Apnea
PCOS
Weight Regain after previous weight Loss Surgery
High Cholesterol
Hiatal Hernia
Issues with Current Lap Band
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5
Who can we contact for results and more information?
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Last Name:
First Name:
Please enter your email
Please enter your phone
Do you prefer for our staff to speak to you in ENGLISH or SPANISH?
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