Patient Evaluation Online Form for Weight Loss Surgery

Are you tired of making excuses for how you feel about yourself?  If you are stuck in a body that is not responding to temporary diets and are ready to commit to your health permanently then it’s time to act NOW!.  There are many reasons for obesity.  The heavier you are, the more you are at the risk of developing serious debilitating medical issues that will have significant impact on your quality of life.
If you are overweight and it prevents you from leading a normal lifestyle and feeling good about yourself, we can help you determine which weight loss surgical procedure is the right option for you.
Weight loss surgery will reduce the adverse effects of excessive weight and alleviate the serious physical, emotional, social and even economic consequences of the disease.

Contact Information
First Name	:	*
Last Name	:	*
Occupation	:	*
Address 1	:	*
Address 2	:
City	:	*
US State	:	Select one... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
Postal Code	:	*
Contact Number	:	*
E-mail	:	*
Clinical Information
Date of Birth	:	Month... January February March April May June July August September October November December Day... 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year... 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 *
Age	:	*
Gender	:	Select one... Female Male *
Height	:	Select one... 4 feet 01 inches 4 feet 02 inches 4 feet 03 inches 4 feet 04 inches 4 feet 05 inches 4 feet 06 inches 4 feet 07 inches 4 feet 08 inches 4 feet 09 inches 4 feet 10 inches 4 feet 11 inches 5 feet 00 inches 5 feet 01 inches 5 feet 02 inches 5 feet 03 inches 5 feet 04 inches 5 feet 05 inches 5 feet 06 inches 5 feet 07 inches 5 feet 08 inches 5 feet 09 inches 5 feet 10 inches 5 feet 11 inches 6 feet 00 inches 6 feet 01 inches 6 feet 02 inches 6 feet 03 inches 6 feet 04 inches 6 feet 05 inches 6 feet 06 inches 6 feet 07 inches 6 feet 08 inches 6 feet 09 inches 6 feet 10 inches 6 feet 11 inches *
Weight	:	*
Previous Weight Loss Surgeries	:	Select One Yes No *
Specify     :
Area of interest	:	Select One Lap Band J & J Band Sleeve Gastrectomy Gastric Bypass Plastic Surgery *
Medical Conditions	:
Additional Information
How were you referred to us	:	Select One Google Yahoo Msn Friend Other *
Enter Friend Name          :           If Other Specify          :
What is your BMI	:	*  Check Your BMI Click Here
Are you interested in financing	:	Select One Yes No *
Time frame for surgery	:	Select One Immediately 3-6 months 6-9 months *
Comments	:
Enter Code	:	*

 

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This website was created for Ready 4A Change, LLC. Your identity, contact and medical information will be treated absolute confidentially and will not be shared with any organizations or individuals outside Ready 4A Change and will be used for the sole purpose of determining your eligibility for the medical procedures you have expressed interest in.

• Ready 4A Change will make the information provided on your e-letter and application available only to the medical and office staff of the doctors we represent.
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CIMA Santa Engracia now CIMA Monterrey has affiliations with the following prestigious US Clinic and Hospitals