Online Consultation

1 | Personal Information

2 | Choose Procedure

Click on the box below to choose the procedure from the drop down menu*
 
—Please choose an option—Sleeve GastrectomyGastric BypassDuodenal SwitchBariatric RevisionInguinal Hernia SurgeryGastric BalloonCholecystectomy – Gallbladder RemovalEndoscopic Sleeve GastroplastyTransoral Outlet ReductionOther Procedure
 

 
Have you had any type of surgery before?
YesNo
 

3 | Photos

For a more comprehensive assessment take and upload your photos. Photographs should cover the abdomen area, front and side.
 

4 | Lifestyle

5 | Medical Conditions

Have you been diagnosed with hepatitis?
YesNo

Have you been diagnosed with HIV?
YesNo

Refused blood transfusions?
YesNo

Have you acid reflux?
YesNo

Do you suffer from allergies?
YesNo

Are you taking any medication?
YesNo

Cardiovascular problems or symptoms?
YesNo

Liver problems or symptoms?
YesNo

Gastrointestinal problems or symptoms?
YesNo

Do you suffer from anxiety?
YesNo

Suffer from convulsions or seizures?
YesNo

6 | Additional Information