Patient Eligibility Form
Filling out this form can be the first step to improving your quality of life! (Please read the following instructions carefully.)
- The information you provide to us is confidential; we do not share or distribute this data as it is used for medical purposes only.
- It is very important to disclose any medical information, especially anemia, diabetes, or any blood abnormality.
- If you have had a previous bariatric surgery, please elaborate on which procedure you had, your initial weight loss, and when you had it. Please provide these details in the "Other" section.
- If your previous bariatric surgery was not laparoscopic (open), please let us know by using the "Other" section.
- Financing is available. If you would like to receive more information, please indicate so in the "Other" section.
- You will receive detailed information about your inquiry via email and a one-time text message. If you have a preferred method of contact (email, text, or call), please let us know by replying to our email or text.
- WE DO NOT charge for providing you with any information, and if you choose to have a virtual consultation, it is also at no cost to you.
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