Patient Information

    Your Name (required)

    Your Email (required)

    Address (required)

    Age

    Height

    Weight

    BMI

    Telephone number

    Emergency Telephone number


    SURGERY
    LapBand
    Bypass
    Sleeve
    Duodenal switch
    Plicature (reversible)
    Revision (convert-bypass)

    Date

    Time

    Surgeon

    Patient coordinator

    Medications (name and dosage)


    Past Medical History:
    Allergies to

    Blood disorders

    Endoscopy with diagnosis of

    Diabetes
    Reflux
    Hypertension
    Heart disease
    Hiatus Hernia
    Gastritis or gastric ulcer
    High Cholesterol/Triglycerides
    Other


    Past Surgical History:


    FLIGHT
    Hotel in mexicali:

    Yes
    No

    Arrival:
    Date:

    Time:

    Flight:

    Airline:

    From:


    Departure:
    Date:

    Time:

    Flight:

    Airline:

    From:

    To:


    PAYMENT
    Total cost:
    USD

    Deposit:
    Yes
    No

    Yes, It is:
    USD

    Payment type:
    Cash
    Money order
    Transfer
    Bank check (no personal check)