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Start Your Consultation

Complete this confidential medical questionnaire so our surgical team can review your case before your consultation. It takes about 8-10 minutes. Your coordinator will contact you within 24-48 hours to schedule your consultation with the surgeon.

Step 1 of 10

Let's start with your contact info

Your coordinator will use this to help you schedule the consultation with the surgeon after we review your medical information.

Please enter your first name.
Please enter your last name.
Please enter a valid email.
Please enter a valid mobile phone.

What are you interested in?

Select all the procedures you'd like the surgeon to consider. You can choose more than one.

Procedures of interest *
Please select at least one procedure.
You can leave this blank if you're flexible.

A little about you

These help the surgeon plan safely.

Please select an option.
Age is required (18+).
Height and weight *
BMI: —
Please enter your height and weight.

Your medical history

Please check any condition you have been diagnosed with. Select all that apply.

Important information for your surgeon

These questions help the surgical team plan your safety. Please answer accurately — everything is confidential.

Confidentiality: Your answers are seen only by the coordinator and your surgeon. This information is protected and never shared publicly.
Have you been diagnosed HIV positive? *
Please answer.
Have you been diagnosed with hepatitis, cirrhosis, fatty liver, or another liver disease? *
Please answer.
Kidney disease?
Bleeding or clotting disorder?

Previous surgeries

Any past surgical procedures, including plastic and non-plastic.

Have you had previous bariatric (weight-loss) surgery?

Lifestyle

Honest answers help us plan a safer recovery.

Do you exercise regularly?
Do you drink alcohol?
Do you smoke? *
Please answer.

Obstetric history

Applies to female patients. Skip if not applicable.

Reference photos

Upload 4 full-body photos: front, back, and both sides. These are essential for the surgeon to plan your procedure.

Privacy notice: Please blur intimate/private areas before uploading. Photos travel encrypted to our server and are seen only by your surgeon. They are never shared or stored on third-party services.
Please upload all four reference photos.

Almost done

Your address helps the coordinator plan travel and follow-up.

State is required.
Please confirm the certification to submit.