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dr_as_info_package.pdf
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Health Questionnaire
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Indicates required field
Name
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First
Last
Phone Number
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Email
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State
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Age
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Gender
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Have you had a Phone Consultation?
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Request a Consultation here (Date and Time)
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Have you paid your 500 USD deposit for Surgery?
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Upload your Deposit info (Photo / Screenshot)
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Max file size: 20MB
Height
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Weight
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BMI
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Proposed Surgical Date (mm/dd/yyyy)
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Desired Medical Procedure
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Do you Have a Passport?
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Date of Birth:
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Occupation
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Emergency Contact (Name)
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Emergency Contact (Phone Number):
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Any of this conditions?
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Sleep Apnea
Heart Disease
Thyroid Issues
Anemia or Bleeding Disorder
Thrombosis or Clotting Disorder
Asthma
Smoking
Diabetes
High Blood Pressure
Any of this conditions?
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Reflux or Heartburn
Gallstones
Allergies
Alcohol / Drugs
Gastroparesis (contraindication for a sleeve)
Back Pain
Kidney or Urinary Disorder
Gastric or Duodenal Ulcer
Hepatitis or Liver Disease
Name Drugs / Allergies Here
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Please List your medications and dosages here:
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Do you have any questions or suggestions for Dr A?
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dr_as_info_package.pdf
File Size:
184 kb
File Type:
pdf
Download File
