Eligibility Application Name: Email: Phone: Select Surgery: Choose ProcedureGastric SleeveGastric PlicationGastric BypassMini Gastric BypassRevision SurgeryGastric BandGastric BalloonDuodenal SwitchPlastic and Cosmetic Surgery Choose Surgery Destination City: Choose DestinationTijuanaCancunCabo San LucasMonterreyPuerto Vallarta Choose Surgeon: Select SurgeonDr. Sergio VerboonenDr. Jaime Ponce De LeonDr. Gerardo Garcia AlvarezDr. Fernando CeronDr. Manuel Garcia GarzaDr. Armando Joya We know you can get busy through out the day. Can we correspond through cellphone text for your convenience? YesNo Medical History Gender MaleFemale Diabetes YesNo Hypertension YesNo Sleep Disorder YesNo Bone Problems YesNo Obesity Related Problems YesNo If yes, briefly explain: Respiratory Problems YesNo Compulsive Eating YesNo Gastro Esophageal Reflux YesNo Low Expectations YesNo Digestive System Problems YesNo Do you smoke? YesNo Hiatal Hernia 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? Please SelectJC UrreaLaura PadillaSheri BurkeMarina BeierNathanie BalliotCarlos VillalpandoDont have one yet How did you hear about us? Please SelectGoogle Search ResultsBing Search ResultsYahoo Search ResultYouTubeForumsReferred by Patient CoordinatorReferred by Friend / FamilySeminarOther 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 SelectYesNo please enter code bellow :
