ROUX-en-Y
Gastric
Bypass

Laparoscopic
Adjustable
Gastric Banding

Causes Of
Obesity

Confidential Inquiry

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*First Name:

*Last Name:

*Age:

*Phone Number:
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*City

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Height:
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Weight:
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STEP ONE

STEP TWO

STEP THREE

STEP FOUR

STEP FIVE

  1. If the surgeon clears you for surgery
  2. If payment source has been verified.
  3. If the necessary releases and agreements are signed and on file
  4. You may be scheduled for surgery within three months.

  1. If the surgeon reviews your situation and determines that more evaluation is indicated.
  2. You will be given instructions.
  3. Possibly a follow-up office visit will be scheduled.



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