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)