Eligibility Application

Select Surgery:
Choose Procedure Gastric Sleeve Gastric Plication Gastric Bypass Mini Gastric Bypass Revision Surgery Gastric Band Gastric Balloon Duodenal Switch Plastic and Cosmetic Surgery Choose Surgery Destination City:
Choose Destination Tijuana Cancun Cabo San Lucas Monterrey Puerto Vallarta Choose Surgeon:
Select Surgeon Dr. Sergio Verboonen Dr. Jaime Ponce De Leon Dr. Gerardo Garcia Alvarez Dr. Fernando Ceron Dr. Manuel Garcia Garza Dr. Armando Joya

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

Yes No

Medical History

Gender
Male Female

Diabetes
Yes No

Hypertension
Yes No

Sleep Disorder
Yes No

Bone Problems
Yes No

Obesity Related Problems
Yes No

If yes, briefly explain:

Respiratory Problems
Yes No

Compulsive Eating
Yes No

Gastro Esophageal Reflux
Yes No

Low Expectations
Yes No

Digestive System Problems
Yes No

Do you smoke?
Yes No

Hiatal Hernia
Yes No

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 Select... JC Urrea Laura Padilla Sheri Burke Marina Beier Nathanie Balliot Carlos Villalpando Dont have one yet Would you like to add Medical Complications Insurance:
Please Select... Yes No How did you hear about us?:
Please Select... Google Search Results Bing Search Results Yahoo Search Results YouTube Forums Referred by Patient Coordinator Referred by Friend / Family Seminar Other

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:

Yes No

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

Click to Put Referal Information

Are you a previous patient?
Please Select... Yes No