Get Started Please complete the Health Questionaire below to get started. Allow a few seconds for the form to load. Patient Name Birth Date Gender Select Male Female Other Select Address Marital status Select Single Married Divorced Widowed Domestic Partnership Select Patient E-mail Mobile Number Weight Height (ft/in) How did you hear about us? Emergency contact Emergency Phone Number Please upload a photo of your ID Have you had Weight Loss Surgery before? Yes No What Weigh Loss Surgery did you had? What surgery are you interested in? Please select a Plastic Surgeon Select Miguel Ángel Esquivel Emanuel Gutiérrez Sergio Soberanos Jorge Galas Martínez Alfredo Chama When are you planning to have your surgery? Have you been diagnosed with any of the following conditions? Allergies Yes No Don´t know Anemia Yes No Don´t know Angina Yes No Don´t know Anxiety Yes No Don´t know Arthritis Yes No Don´t know Asthma Yes No Don´t know Atrial Fibrillation / Arrythmia Yes No Don´t know Blood Cloths Yes No Don´t know Cancer Yes No Don´t know Cerebrovascular Yes No Don´t know Coronary Artery Disease Yes No Don´t know Crohns Disease Yes No Don´t know Depression Yes No Don´t know Diabetes Yes No Don´t know Gallbladder Disease Yes No Don´t know GERD Yes No Don´t know Hepatitis C Yes No Don´t know Hyperlipidemia Yes No Don´t know Hypertension Yes No Don´t know Irritable Bowel Disease Yes No Don´t know Liver Disease Yes No Don´t know Migraine Headaches Yes No Don´t know Myocardial Infarction/Heart attack Yes No Don´t know Osteoarthritis Yes No Don´t know Osteoporosis Yes No Don´t know Peptic Ulcer Disease Yes No Don´t know Renal Disease Yes No Don´t know Seizure Disorder Yes No Don´t know Do you currently take any medications? Yes No Do you currently suffer from any illness? Yes No Have you every underwent any surgical procedure? Yes No Have you had skin or wound healing problems? Yes No Does your scars tend to hypertrophy or keloid? Yes No Drink alcohol? Yes No sometimes Smoke or use nicotine products? Yes No sometimes Ingest caffeine? Yes No sometimes Use any recreational drug? Yes No sometimes Do you have any medical history not yet covered? Following these photo guidelines will help our plastic surgeons customize a treatment plan for you. Breast surgery photos: 1. Front view of neck, shoulders, breasts, and navel 2. Front view of both arms raised above the head 1 left side view (both arms to the side) 1 right side view (both arms to the side) 1 left body profile 1 right body profile 1 front in profile from the knees up 1 back in profile from the knees up y agreeing to these terms and conditions you OPT-IN to being contacted by International Metabolic Bariatric Center SC via Text Messages, Email, WhatsApp, and/or Phone. To opt-out, simply reply "STOP". Your information is NEVER sold or used by 3rd party companies.1. All information that you are required to provide with this Health Questionnaire, as well as any other medical information thereafter, is required to be truthful, complete, and accurate. If it is not accurate, the surgeon can cancel your surgery resulting in the loss of security deposit and all monies paid for the surgery.2. It is imperative that the height and weight reported on the Health Questionnaire be accurate. ALL patients are weighed and measured before surgery. If the BMI (Body Mass Index) at the time of surgery does not accurately reflect the height and weight reported on the Health Questionnaire, the surgeon(s) may exercise their right to forego the surgical procedure and any deposit made will be forfeited.3. If you decide to schedule your surgery, we reserve the right to be able to contact you via phone, email, WhatsApp, and/or text. Any previous settings for those communication methods to be disabled will be overridden. Your information is not shared or sold. Your health information is kept private only to be seen by International Metabolic Bariatric Center SC and necessary parties involved.Deposit, Refund, & Cancellation Policy (If Surgery is Scheduled)International Metabolic Bariatric Center SC® (IMBC) posts its deposit, refund, and cancellation policy that is documented on the Health Questionnaire (HQ) and the Consent Form. This policy applies to all surgeons and surgery types offered through International Metabolic Bariatric Center SC. Please contact your patient coordinator if you have any questions regarding these policies.Deposit and Booking Bariatric Send
