Am I Eligible for Surgery? START HERE
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Dr. Perez Corzo
Hospital
Obesity Good Bye Hospital
Surgery Options
Gastric Sleeve Surgery
Gastric Band Surgery
Gastric Bypass Surgery
Mini Gastric Bypass Surgery
Gastric Revision Surgery
Gastric Balloon Surgery
Duodenal Switch Surgery
Hiatal Hernia Repair
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About Tijuana
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Am I Eligible? START HERE
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First Name
Last Name
Email Address
Phone Number
Booking Date
Choose Procedure
Choose Procedure
Gastric Sleeve
Gastric Sleeve (Single Incision)
Gastric Plication
Gastric Bypass
Mini Gastric Bypass
Revision Surgery
Gastric Band
Gastric Balloon
Duodenal Switch
Choose Destination
Tijuana
Select Surgeon
Dr. Hector Perez Corzo
We know you can get busy through out the day. Can we correspond through cellphone text for your convenience?
Please Select...
Yes
No
Enter Age
Enter Height
Enter Weight
Gender
Yes
No
Diabetes
Yes
No
Hypertension
Yes
No
Sleep Disorder
Yes
No
Bone Problems
Yes
No
Obesity Related Problems
Yes
No
If yes, briefly explain:
Respiratory Problems
Yes
No
Compulsive Eating
Yes
No
Gastro Esophageal Reflux
Yes
No
Low Expectations
Yes
No
Digestive System Problems
Yes
No
Do you smoke?
Yes
No
Hiatal Hernia
Yes
No
If you answered yes, are you in treatment and what is your treatment?:
hat kind of diets have your carried out? (how long?):
Any allergies that the doctor should know about? (please list):
Currently taking Medications? (please list):
Have you had previous abdominal surgeries? (If yes, explain):
Who is your patient coordinator?:
JC Urrea
Carlos Villalpando
Dont have one yet
Would you like to add Medical Complications Insurance:
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No
How did you hear about us?:
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Google Search Results
Bing Search Results
Yahoo Search Results
YouTube
Forums
Referred by Patient Coordinator
Referred by Friend / Family
Seminar
Other
Not listed on how you heard about us? type in here:
Do you have a friend or family member that would like to refer to us? Receive $100 per patient referral:
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No
If you answered yes, please write down your referrals names and cell phone numbers:
Are you a previous patient?
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