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APPLY FOR SURGERY

Take the First Step Toward a Healthier Life

Deciding to have weight loss surgery is a life changing decision. Our online Weight Loss Surgery Application is designed to make the process simple, secure, and stress free. By completing the application, you’ll help our medical team understand your health history, goals, and unique needs so we can recommend the safest and most effective treatment plan for you.

Why Complete the Application?

  • Personalized Care: Every patient’s journey is different. Your answers give our surgeons and care team the information needed to guide you to the right procedure.
  • Faster Approvals: Submitting your details in advance allows us to prepare your evaluation and shorten the time between your application and your surgery date.
  • Direct Connection: Once your application is reviewed, a coordinator will reach out to you to discuss next steps, answer your questions, and schedule your surgery consultation.
  • Confidential & Secure: All information is encrypted and handled according to strict privacy standards.

What You’ll Need

When filling out the application, please have the following details ready:

  • Basic personal information (name, contact details, date of birth).
  • Medical history (past surgeries, current conditions, medications).
  • Lifestyle information (diet, activity level, smoking or alcohol use).

The form usually takes 10–15 minutes to complete.

What Happens Next?

  • Submit Your Application – Once completed, your information is securely sent to our team.
  • Medical Review – Our specialists will carefully evaluate your health profile.
  • Personalized Recommendation – You’ll receive guidance on the surgery options best suited for your case, such as gastric sleeve, gastric bypass, or revision surgery.
  • Scheduling & Support – A patient coordinator will contact you to arrange your surgery date, discuss travel (if required), and guide you through every step.

Weight Loss Surgery Application Form

Please enable JavaScript in your browser to complete this form.
Name
Address City state zip

BMI Calculator

Enter your values—your BMI updates automatically.

Example: 5 ft 10 in → enter 5 and 10.

Any Medical/physical problems i.e. sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurological disorders, etc.
Are you currently taking any medications or herbal supplements
Is there a history in your family of diabetes, cancer, and/or hypertension
Any surgeries i.e. gallbladder, appendix, hernia, heart, etc.
Do you have any adverse reaction to anesthesia
Do you have dentures, dental implants, or caps?
Do you have any children?
Do you have heavy periods?
Do you smoke?
Do you drink?
Do you do drugs?
Do you currently take any of the following medications?
Have you ever been treated for cancer with chemotherapy or radiation therapy?Do you do drugs? (copy)
Do you currently have any problems with your:
Have you or anyone in your family ever had a serious bleeding problem?
Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed?
Do your gums bleed when you brush your teeth?
Are you pregnant?
Is there any possibility that you are pregnant?
Have been told you have diabetes?
Do you wake up to urinate more than once at night?
Do you have muscle cramps or pains?
Do you have problems with your lungs or chest? (e.g., chest pain, skipped heart beats, high blood pressure, smoke one or more packs a day, shortness of breath, emphysema, asthma, bronchitis) underline all that apply
Do you have a cough, or cough frequently?
Do you have epilepsy or suffer from fits or seizures?
Do you have neck or back problems?
Are you scheduled for surgery?
Where you referred by anyone?
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