833 300 3010 info@bariatricsmx.com

Candidate form

SEE IF YOU QUALIFY

FOR WEIGHT LOSS SURGERY

    Are you at least 21 years of age?*

    Have you have failed previous attempts at weight loss with conventional dieting and lifestyle changes?*

    Have you been diagnosed with diabetes, high blood pressure, high cholesterol, or sleep apnea?*

    What is your current weight (LBS)?*

    What is your height? (inches)*

    What is your gender?*

    Surgery Interest?*

    Phone Number*

    Your Name*

    The results will be sent to your email instantly.

    Pre-screen Health Form

    Please read carefully so we can get an accurate understanding of your health.

     

    • Provide your first and last name exactly as it appears on your ID or driver’s license.
    • Make sure to use a valid email address to confirm your pre-screening form.

     

    We respect your privacy and confidentiality. We will never sell or share your information with third parties. It will only be disclosed when absolutely necessary and with your prior consent. You also agree to receive follow-up communication from our coordination team via email, phone, and occasional text messages.