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)