Patient Eligibility Form
- Your information is confidential and used for medical purposes only. We do not share it.
- Please disclose any medical conditions, including anemia, diabetes, or blood disorders.
- If you’ve had previous bariatric surgery, indicate the procedure, date, and initial weight loss in the "Other" section. Open (non-laparoscopic) surgeries have an additional $700 fee — please note if applicable.
- Financing is available — let us know in the "Other" section if interested.
- You’ll receive information via email and a one-time text. To specify your preferred contact method, reply to our message.
- Providing information and virtual consultations are free of charge.
* = required
