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Select Surgery: Please Select... Gastric Sleeve Gastric Plication Gastric Bypass Mini Gastric Bypass Revision Surgery Gastric Band Gastric Balloon Plastic and Cosmetic Surgery

When are you planning to have surgery?: Please Select... ASAP Would Like to Book Now 1-2 months 3-6 months More than 6 months Don't know yet

Surgeon Inquiring About: Please Select... Dr. Sergio Verboonen Dr. Jaime Ponce De Leon Dr. Gerardo Garcia Alvarez Dr. Fernando Ceron Dr. Manuel Garcia Garza Dr. Armando Joya

Choose Surgery Destination City: Please Select... Tijuana Cancun Cabo San Lucas Monterrey Puerto Vallarta

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

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Comments:

Are you a previous patient?:
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Select Surgery: Please Select... Gastric Sleeve Gastric Plication Gastric Bypass Mini Gastric Bypass Revision Surgery Gastric Band Gastric Balloon Plastic and Cosmetic Surgery

Choose Surgery Destination City: Please Select... Tijuana Cancun Cabo San Lucas Monterrey Puerto Vallarta

Select Surgeon: Please Select... Dr. Sergio Verboonen Dr. Jaime Ponce De Leon Dr. Gerardo Garcia Alvarez Dr. Fernando Ceron Dr. Manuel Garcia Garza Dr. Armando Joya

Select Surgery Date: Please note: Surgery dates are subject to chance opon surgeon and hospital availability
January February March April May June July August September October November December		1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31		2016 2017
	Month		Day		Year

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

Yes No

Comments:

 

For security, please enter above code bellow*:

Select Surgery: Please Select... Gastric Sleeve Gastric Plication Gastric Bypass Mini Gastric Bypass Revision Surgery Gastric Band Gastric Balloon Plastic and Cosmetic Surgery

When are you planning to have surgery?:
Please Select... ASAP 1-2 months 3-6 months More than 6 months Dont know yet

Select Surgeon: Please Select... Dr. Sergio Verboonen Dr. Jaime Ponce De Leon Dr. Gerardo Garcia Alvarez Dr. Fernando Ceron Dr. Manuel Garcia Garza Dr. Armando Joya

Choose Surgery Destination City: Please Select... Tijuana Cancun Cabo San Lucas Monterrey Puerto Vallarta

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

Yes No

Height:*

Weight:*

Age:*

Gender

Male Female

Medical History

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 (Coverage up to $160,000.00 USD):
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? ($100 per referral):

Yes No

If you answered yes, please write down your referrals:

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

 

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