Bariatric Medical Questionnaire

In order to determine your candidacy for weight loss surgery and to take it to the next level, we request you to fill out our Bariatric Medical Questionnaire.

Download Bariatric Questionnaire

To speed up the process we recommend filling the medical history questionnaire which will be reviewed by the bariatric surgeon. (All the information will be kept confidential.) Please make sure that the information you provide is accurate and to the best of your knowledge. It is imperative that we have a thorough understanding of your health profile to decide if you are a candidate for bariatric surgery.

Please send the filled medical questionnaire to info@ 
Our process includes the following steps:

  1. Fill out the Medical Questionnaire form. Email it to info@ or fax it back to us to 469-941-0606.
  2. The medical questionnaire will be reviewed by the surgeon. An audio/video teleconference with the doctor can also be arranged, if desired.
  3. Once you are approved for the surgery and a surgery appointment is confirmed (based on your desired date, doctor’s schedule, and hospital availability), make necessary flight arrangements. Our case managers can guide you in this regard. At this point our on-site nutritionist will provide you customized pre-op diet plan and instructions. She will also be available for any related questions.
  4. Immediately on approval and confirmation of a surgery date a refundable deposit is to be made, details of which will be emailed to you.
  5. Before your arrival to the surgery location, our destination manager, nutritionist, and drivers will contact you.

We respect your privacy. Please go through our privacy policy statement.

(In case you are not able to access the PDF format, please ask us (info@ to email you the questionnaire in Word format.)