Bariatric Surgery Application Form - A Slimmer Me Tijuana

Bariatric Surgery Application Form


First name
Last name
Max Weight


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Phone 1

Phone 2
Phone 3

Name of person of contact in case of emergency:
Phone in case of emergency:
Select the procedure you are interested in:
Type of package:

Medications (that you are currently taking):

Do you take, or have you taken in the past Blood-thinners? (if yes, explain why) YesNo
Do you have allergies?
Others (include antibiotics and pain medications)

Medical problems

Have you had or do you have now?

If yes to any medical problem, please explain date of diagnosis and treatment received:

Surgical History

Have you ever had a problem with an anesthetic? (explain, if yes) YesNo
Have you ever had bariatric surgery? (what type of surgery) YesNo
Have you had a plastic surgery procedure before? YesNo
If yes. What was the procedure?
When did you had it done?

General Health

Do you currently:

Smoke cigarettes? YesNo
Number of years?
Quit? If you have quit: When?
How long?
Drink Alcohol? YesNo
Use recreational drugs? YesNo
Have you ever used intravenous drugs (or skin-popping)?
Are you easily fatigued: YesNo
Do you have shortness of breath? YesNo
Do you use a B-PAP or C-PAP while you sleep? YesNo
Do you have asthma? YesNo

Gynecologic History (for women)

Date of last menstrual period:
Bleeding is:NormalLightHeavyIrregular

Number of pregnancies
C-section: YesNo
Type of Birth Control used (If oral contraceptives, how many years?)
Are you presently, or have you ever taken hormones? YesNo
If yes, what type and for how long?
Are you pregnant? or is there a possibility of you being pregnant?
How did you hear about us? GoogleFacebookYoutube/VimeoTwitterWeb forumsFriendInstagramRadioE-mail
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By checking this box you are validating that everything you have giving ASM on your medical history it's valid and will not be altered in any way because that would put your health at risk.
You have 48 hours to cancel after deposit is made in order to receive a full refund. After 48 hours, 10% of the cost of your procedure will be kept by the facility for all arrangements previously made for your procedure. Any reimbursement will take between 1-2 weeks working days. In the event of a suspended procedure due to health issues found the facility will charge $515 dlls to cover all medical expenses. Any cancellations that are a cause of not following ASM pre-op diet will have a 60% penalty of your procedure. In case the patient does not show up with out prior notice or rescheduled surgery date, there will be no return of deposit made towards your surgery. For rescheduling you will have 3 weeks before your locked date. Rescheduling during the 3 weeks prior your surgery date will make you lose your initial deposit, having to start the application process all over again. You can only reschedule once. If by any means you have to reschedule a second time, you will lose your initial deposit and it will be as if you are applying for the first time.
Remember that this is about a LIFE COMMITMENT DECISION, that will not only make you feel better in every aspect of your life, but it will also make you a HEALTHIER PERSON.
Let's commit to us! for a better life, for more dreams and paths to open up.