Contact Information
First Name:
Last Name:
Email:
Country:
Select a Country
United States
Canada
Mexico
US State:
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Canadian Province/Territory:
Select a Province/Territory
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Northwest Territories
Nunavut
Mexican State:
Select a State
Aguascalientes
Baja California
Baja California Sur
Campeche
Chihuahua
Chiapas
Coahuila
Colima
Durango
Guanajuato
Guerrero
Hidalgo
Jalisco
México
Michoacán
Morelos
Nayarit
Nuevo León
Oaxaca
Puebla
Querétaro
Quintana Roo
San Luis Potosí
Sinaloa
Sonora
Tabasco
Tamaulipas
Tlaxcala
Veracruz
Yucatán
Zacatecas
Phone:
+1 (USA)
+1 (CAN)
+52 (MEX)
Personal Information
Age:
Gender:
Male
Female
Other
Height:
150 cm (4'11)
152 cm (5'0)
155 cm (5'1)
157 cm (5'2)
160 cm (5'3)
163 cm (5'4)
165 cm (5'5)
168 cm (5'6)
170 cm (5'7)
173 cm (5'8)
175 cm (5'9)
178 cm (5'10)
180 cm (5'11)
183 cm (6'0)
185 cm (6'1)
Weight:
Under 68 kg (Under 150 lbs)
68-91 kg (150-200 lbs)
91-113 kg (201-250 lbs)
113-136 kg (251-300 lbs)
136-159 kg (301-350 lbs)
Over 159 kg (Over 350 lbs)
Medical Record
Do you smoke?
Yes
No
Some times
Previous Surgeries
Bariatric Surgery
Plastic Surgery
Oncologic Surgery
Other Surgery
Health conditions:
Acid reflux
Diabetes
Heart Disease
Hypertension
Sleep Apnea or Lung disease
Anxiety or Depresion
HS Vein Thrombosis
Other Health Information:
Procedure of Intereset
Gastric Sleeve
Mini gastric bypass
Gastric Bypass
SADI-S
Intestinal Transit Bipartition
Revisional Surgery (Not my first bariatric surgery)
Adjustable Gastric Band Removal
Other
Not Sure
Comments or Concerns
Please fill in all required fields.