• Medical Assessment

    Completely confidential with no obligation!

  • Please complete the following information to see if you are a suitable candidate for bariatric surgery. This information is securely shared only with your surgeon. 

  • Client Status

  • Contact Information

    Please complete the information below
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  • Surgery Details

    Please tell us the procedures you are interested in
  • Requested Date of surgery (If Known)
     - -

  • Medical

    Please complete both the family and patient medical sections

  • Your Family Medical

    Please indicate if you have a history of these conditions in your family. 

  • Heart Disease*
  • Diabetes*
  • Hypertension*
  • Asthma*
  • Cancer*
  • Heart Disease*
  • Heart Disease*

  • Your Personal Medical

    Please indicate if you have any of the following.  If yes, please indicate any details for the surgeon. 

  • Heart Disease*
  • Diabetes*
  • Hypertension*
  • Deep Vein Thrombosis*
  • Cardiovascular Accidents*
  • Asthma*
  • Bleeding Tendency*
  • Hyperthyroidism*
  • Adrenal Insufficiency*
  • Hepatitus*
  • HIV*
  • Keloid Scarring*
  • Cancer*
  • Major Operation*
  • Other*
  • Underlying Disease*
  • Drug Allergies*
  • Food Allergies*
  • Current Vitamins, food nutritional supplements*
  • Current Medications and dosage*
  • Ever been treatmented for depression?*

  • Habits

    Please describe your current personal habits
  • Drinking?*
  • Smoking?*

  • Women

    This section is for women only
  • Pregnant Now?
  • Birth control pills, hormone replacement medications, hormone patch or implant?
  • Planning for more pregnancies?

  • Files (Optional)

    If you wish to provide additional documentation
  • Upload Files
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  • Thank You for Completing!

    PLEASE SUBMIT BELOW WHEN COMPLETE.

  • We will forward this information to your surgeon for review and feedback. In the interim please let us know if you have any questions. 

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