Premier Bariatric Institute
Tel: 773 365 1300 I Fax: 773 365 1515
Bariatric Surgery Application Request for SelfPay
Sofiane El Djouzi, MD, FACS
Last Name
*
First Name
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Cell Number
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Please enter a valid phone number.
Email
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example@example.com
Have you ever had bariatric surgery before?
No
Yes
Are you looking for bariatric surgery revision?
No
Yes
Which bariatric procedure appeals most to you?
*
Please Select
Undecided
Laparoscopic Assisted Robotic Vertical Sleeve Gastrectomy (Gastric Sleeve)
Laparoscopic Assisted Robotic Roux-en-Y Gastric Bypass
Laparoscopic Assisted Robotic Single Anastomosis Duodenal Switch (SADI-S)
Laparoscopic Assisted Robotic Adjustable Gastric Band (Lap-Band)
In Need of Bariatric Surgery Revision
Endoscopic Sleeve Gastroplasty
Endoscopic Gastric Balloon
Other
Do you hold any medical insurance?
*
Please Select
No
Yes
What is your medical insurance?
Take a clear photo of the back of the medical insurance card
Take a photo of the front of the medical insurance card
Your journey towards enhanced health and well-being is just a step away. We invite you to schedule your self-pay consultation with Dr. El Djouzi. Are you prepared to take this important next step in your care journey?
*
Yes
No
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