Application

Home address *

Please provide all the phone numbers and the best time where we can reach you*

Allergic to any food? YesNo

Last Menstrual Cycle date:

Do you use any hormonal contraception? YesNo

Do you have very heavy periods?YesNo

Do you suffer from infertility? YesNo

Have you had abnormally high blood glucose levels during one of your pregnancies? YesNo

When did you start to be overweight?

Have you been diagnosed with Hepatitis B? YesNo

Have you been diagnosed with Hepatitis C?YesNo

Have you been diagnosed with HIV?YesNo

Do you refuse Blood transfusion? YesNo

Do you have Type II Diabetes or Impaired Fasting Blood Glucose? YesNoDon't Know

Do you have High Blood Pressure? YesNoDon't Know

Do you have high blood lipids or cholesterol? YesNoDon't Know

Do you have heart disease? NoneHeart attackCardiomyopathyHeart valve diseaseHeart Failure

Do you have a pacemaker? YesNoDon't Know

Do you have any problems with your lungs?NoneAsthmaCOPDFrequent InfectionsLung Tumor

Do you have Sleep Apnea? YesNoDon't Know
Answer YES if you use CPAP or BIPAP machine

Were you ever treated for blood clots in your leg(s)? YesNo

Do you have Liver Disease? NoneFatty LiverCirrhosisLiver tumorOther

Do you have any of the following? GallstonesAcid Reflux (heartburn)Stomach Ulcers

Do you have kidney or bladder problems? NoneKidney StonesLose urine when laughKidney FailureOther

Were you ever diagnosed with Cancer? YesNo

Any history of seizures or epilepsy?: YesNo

Are you diagnosed with any psychiatric illness? YesNo

Are you currently under psychiatric treatment? YesNo

Have you had previous surgery such as? No previous surgeryAbdominal Hernia repairSmall bowel removalColon surgeryCaesareanTube LigationHysterectomyBreast augmentation/liftTummy tuck

Have you had Bariatric Surgery? NoneLap BandGastric SleeveGastric BypassGastric BalloonRevision Surgery

Please list all the medications you are taking (dosage, frequency, reason):

Do you take anticoagulants (blood thinners) such as?NoneCoumadin (also called Warfarin)AldeparinDalterarinDanaparoid

Do you take anti-platelet drugs such as? NoneAspirin 81 mgTriflusal (Disgren)Prasugrel (Effient)Cilostazol (Pletal)Eptifibatide (Integrilin)TerutrobanTicagrelor (Brilinta)Vorapaxar (Zontivity)Tirofiban (Aggrastat)Clopidogrel (Plavix)TiclopidineHeparinAbciximab (ReoPro)Dipyridamole (Persantine)EnoxaparinOther

Is there anything related to your medical history that has not been covered?

Do you have any question for your surgeon or your medical team?

Do you have any physical limitations that require the use of prosthesis, crutches or
wheelchair?

I am interested in the following surgery:Gastric SleeveGastric BypassMini Gastric BypassGastric PlicatureRevision of Previous SurgeryWill discuss options

I understand that I am requesting surgery in the private sector and that I will have to pay for this surgery. I understand that Weight Loss Surgery and its suppliers of services will collect personal information relating to me in order to prepare and carry out my surgery and to invoice me the expenses, costs and fees which correspond to it. I understand that the file containing my personal information will be preserved by Weight Loss Surgery or its suppliers of services at their offices or on their electronic servers and that their employees who require it in the performance of their duties will have access to this file.

I grant this collection and use of my personal information for this purpose. I hereby authorize Weight Loss Surgery Inc. to disclose my individually identifiable health information to the bariatric surgeons and staff of Weight Loss Surgery. This information will be used to assess my candidacy for bariatric surgery and allow the team to provide all preoperative, operative and post-operative care.

I understand that both Weight Loss Surgery Inc. and its bariatric surgeon and staff agree to abide by the NOTICE OF PRIVACY PRACTICES which is available for inspection at any time.

I have read and understand the terms.