Apply for Surgery

APPLY FOR SURGERY

APPLY FOR BARIATRIC SURGERY HERE! YOU CAN FILL THE ONLINE FORM OR DOWNLOAD OUR APPLICATION FORMS PROVIDED BELOW, PRINT THEM AND FILL THEM OUT.

OUR DOCTORS WILL EVALUATE YOUR MEDICAL CONDITIONS AND CLEAR YOU FOR SURGERY WITHIN 24 HRS. YOU CAN EXPECT THEIR ANSWER THROUGH THE E-MAIL SUBMITTED ON THIS FORM.

Procedure:
ChooseGastric BypassGastric SleeveMini Gastric BypassRevision SurgeryLap BandPlastic Surgery

Patient facilitator name:

First Name*

Last Name*

Age:

E-mail:*

Height:*

Weight:

BMI:

Address:

Street Address:

City:

State / Province / Region:

Postal / Zip Code:

Country:

---AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Phone (Home):*

Phone (Cell):

Maximum Weight:

When?:

List All Allergies

Allergies:

Date of Birth:

Date of Surgery:

Name of person to contact in case of emergency:

Emergency Phone:

*Any Medical/physical problems (i.e., sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurological disorders, etc.)?*
YesNoDon't Know
If Yes, please list:

Are you currently taking any medications or herbal supplements?
YesNoDon't Know
If Yes, please list the name, dosage and reason for this medicine):

Is there any history in your family of diabetes, cancer and/or hypertension?
YesNoDon't Know
If Yes, please indicate which ones:

Any surgeries (i.e., gallbladder, appendix, hernia, heart, etc.)?
YesNoDon't Know
If Yes, please list:

Do you have any adverse reaction to anesthesia?
YesNoDon't Know
If Yes, please indicate the reaction:

Do you have dentures, dental implants, or caps?
YesNoDon't Know
If Yes, please indicate where:

Do you have any children?
YesNo
If so, how many?

Do you have heavy periods?
YesNo

Do you smoke cigarettes?
YesNo
If so, how many cigarettes a day?

Do you drink?
YesNo
If so, how many drinks?

Do you do drugs?
YesNo
If so, what kind and how often?

Pre-Operative Assessment

Patient Name:

Patient Age:

Patient Sex: MaleFemale

Date:

For the Following Questions, Please Indicate "Yes" "No" or "Do Not Know". Please answer all of the questions.

1. Do you currently take any of the following medications?

a) Aspirin (excedrin, anacin, bufferin)
YesNoDon't Know

b) Anticoagulants (blood-thinning medicine)
YesNoDon't Know

c) Propanol, Verapamil (heart rhythm medicines)
YesNoDon't Know

d) Diuretics (water pills)
YesNoDon't Know

e) Antihypertensive drugs (blood pressure pills)
YesNoDon't Know

f) Digitalis (heart pills)
YesNoDon't Know

g) Stereoids (prednisone, cortisone)
YesNoDon't Know

1. Do you smoke one or more packs a day,
YesNoDon't Know

2. Have you ever been treated for cancer with chemotherapy or radiation therapy?
YesNoDon't Know
If Yes, When:

3. Do you currently have any problems with your:

a) Liver (e.g. cirrhosis, hepatitis, yellow jaundice)
YesNoDon't Know

b) Kidneys (infection, stones, failure)
YesNoDon't Know

c) Spleen
YesNoDon't Know

d) Blood (anemia, leukemia)
YesNoDon't Know

4. Have you or anyone in your family ever had a serious bleeding problem?
YesNoDon't Know

5. Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed?
YesNoDon't Know

6. Do your gums bleed when you brush your teeth?
YesNoDon't Know

7. Are you pregnant?
YesNoDon't Know

8. Is there any possibility that you are pregnant?
YesNoDon't Know

9. Have been told you have diabetes?
YesNoDon't Know

10. Do you wake up to urinate more than once at night?
YesNoDon't Know

11. Do you have muscle cramps or pains?
YesNoDon't Know

12. Do you have problems with your lungs or chest? (e.g., chest pain, skipped heart beats, high blood pressure, smoke one or more packs a day,(1)
YesNoDon't Know
shortness of breath, emphysema, asthma, bronchitis) if yes please list:

13. Do you have a cough, or cough frequently?
YesNoDon't Know

14. Do you have epilepsy or suffer from fits or seizures?
YesNoDon't Know

15. Do you have neck or back problems?
YesNoDon't Know

16. Are you scheduled to have an operation?
YesNoDon't Know
If Yes, what operation?

17. Are you currently taking any medications?
YesNoDon't Know
If Yes, please list medications:

The recommended surgery for obese patients with GERD or severe acid reflux is the Gastric Bypass. The bypass is the anti reflux surgery for weight loss. The sleeve can actually cause more reflux that may or may not be controlled with medication. In the case that the reflux is not controlled by medication you will need to consider converting your sleeve into a gastric bypass to prevent serious repercussions from the acids

Did anyone refer you?*
YesNo
Pleas tell us how you found out about Long Term VSG:
Select valueTelephoneYoutubeGoogleYahooBingWhatclinicObesity HelpReal SelfBariatric PalBlog
if yes, please write referer's name

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