How long have you thought about surgical options for your weight loss? *
How long have you struggled with obesity? *
What is your highest weight? *
Has anyone in your family had bariatric surgery?
Which surgical procedure are you interested in (check all that apply):
How did you hear about our program?
Name of referring physician: *
Primary Care Physician Information:
Are you a Jehovah’s Witness? *
Please list all the medications you are currently taking and the dosage: *
Do you have any drug allergies? *