Affordable Weight Loss Surgery in Mexico & Henderson, NV | Bariatric Surgery, Plastic Surgery, & More | Bariatric Surgery Solutions
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Home» Eligibility Application

Eligibility Application

    Name:

    Email:

    Phone:

    Select Surgery:

    Choose Surgery Destination City:

    Choose Surgeon:

    We know you can get busy through out the day. Can we correspond through cellphone text for your convenience? YesNo

    Medical History

    MaleFemale

    YesNo

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    YesNo

    If yes, briefly explain:

    YesNo

    YesNo

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    YesNo

    YesNo

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    YesNo

    If you answered yes, are you in treatment and what is your treatment?:

    What kind of diets have your carried out? (how long?):

    Any allergies that the doctor should know about? (please list):

    Currently taking Medications? (please list):

    Have you had previous abdominal surgeries? (If yes, explain):

    Who is your patient coordinator?

    How did you hear about us?

    Not listed on how you heard about us? type in here:

    Do you have a friend or family member that would like to refer to us?
    Receive $100 per patient referral: YesNo

    If you answered yes, please write down your referrals names and cell phone numbers:

    Are you a previous patient?

    please enter code bellow : captcha

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