* The information you provide will help us to propose the best treatment for you, for which we ask you to respond with care and sincerity.
Have you had any surgery for weight control?
Have you suffered a heart attack?
Indicate any additional information that you think is important in the evaluation of your health status
I understand that it is important to give complete and true information for my own safety; so I have filled out this questionnaire with all the information I know, and I have answered with complete sincerity for my own health and safety.
If utilizing United Medical Credit to finance a procedure, a service fee of 10% will be added to the price of the surgery.
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