Application - drfredylopez

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It is important to fill out the medical questionnaire honestly and as accurate as possible to ensure you receive the premium care you deserve

This will take approximately 10-15 minutes to complete.

Complete Health Questionnaire

Once your medical coordinator reviews your health history form, your patient coordinator will be in contact with you to review pre-surgical instructions.

Start Health Questionnaire form by clicking the start button at the bottom

Pay Your Deposit to Secure Your Surgery Date

Complete your Health Questionnaire.
Pay your deposit to secure your surgery date.

Our medical team will review your application and we will work with you to achieve optimal pre-surgical health parameters.

Our patient coordinator will work with you to pick a date for your surgery.

Simply pay your deposit safely online.

* A $500 deposit is required.

* (Deposit is partially refundable on rescheduling surgery date, but not surgery cancelations).

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What's your name? *

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What's your last name? *

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have you been a patient of us before? *

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What is your biological sex? *

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Female

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What is your date of birth? *

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How old you? *

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What is your phone number? *

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Please provide us with a secondary phone number:

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What is your email? *

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Next we will ask you for your address:

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Please provide us with your street name and number *

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Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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What procedure are you interested in? *

Gastric Bypass
Gastric Balloon
Duodenal Switch
Revision Surgery
Gastric Sleeve
SADI

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Next we will ask you for your emergency contact

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Full name of emergency contact *

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Emergency contact phone *

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Next we will ask you for details about your health

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What has been your maximum weight? *

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What is your current weight? *

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What is your height?

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Do you currently take any medication? *

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Please specify the name, reason, dose, and frequency of the medications you take *

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Do you take or have you taken any anticoagulant before? *

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Which is the reason? *

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Next we will ask you about possible allergies

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Are you allergic to penicillin? *

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Are you allergic to sulfa drugs? *

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Are you allergic to iodine? *

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Are you allergic to adhesive tape? *

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Are you allergic to latex? *

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Are you allergic to aspirin? *

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Specify any other allergies you may have

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Next we will ask you about your medical history

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Do you have or have you had an addiction?

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Specify any addictions you have or have had. *

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Do you have or have you had high lipid levels?

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Date of diagnosis of high lipid levels *

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Do you have or have you had arthritis? *

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Arthritis diagnosis date *

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What was the treatment to treat the arthritis? *

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Do you suffer or have you suffered from high cholesterol and triglycerides levels? *

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High cholesterol and triglycerides levels diagnosis date *

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What was the treatment for cholesterol and triglycerides? *

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Have you had a heart attack? *

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Date of heart attack diagnosis *

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What was the treatment for the heart attack? *

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Do you suffer from diabetes? *

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Diabetes diagnosis date *

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What is the assigned treatment for diabetes? *

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Do you suffer or have you suffered from coronary artery disease? *

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Coronary artery disease diagnosis date

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What was the treatment for coronary artery disease? *

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Do you have or have you had cancer *

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Date of cancer diagnosis? *

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What was the treatment for the cancer *

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Do you suffer or have you suffered from any liver disease? *

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Liver disease diagnosis date *

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What was the treatment? *

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Do you suffer or have you suffered from any lung disease? *

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Diagnosis date *

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What was the treatment? *

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Do you suffer or have you suffered from kidney disease? *

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Diagnosis date *

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What was the treatment? *

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Do you suffer or have you suffered from any disease of the thyroid gland? *

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Diagnosis date *

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What was the treatment? *

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Do you suffer or have you suffered from hypertension?

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Diagnosis date *

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What was the treatment? *

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Do you suffer from any other disease not mentioned above?

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Specify the name of the diseases, dates of diagnosis and treatments *

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Next we will ask you about your gynecological history

If it does not apply to you, please skip the following questions until you reach the surgical history section.

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Date of your last menstrual period

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How was the bleeding?

Strong
Normal
Light
Irregular

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Have you been pregnant?

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How many times have you been pregnant?

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Of your pregnancies, how many have required cesarean section?

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Do you take any kind of contraceptive?

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Specify the types of contraceptives you take and for how long you have taken them

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Do you currently take or have you taken any kind of hormones?

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Specify here the types of hormones and for how long you have taken them

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Are you currently pregnant?

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Next we will ask you about your surgical history

If you skipped the gynecological history questions please continue here

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Have you had any surgery before? *

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Specify the type of surgery, age, year of surgery, and complications if any *

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Have you had any complications with an anesthetic? *

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What was the complication *

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Have you had any bariatric surgery? *

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Specify the type of bariatric surgery and the year in which it was performed *

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Have you had any plastic surgery?

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Specify the type of plastic surgery and the year it was performed *

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Next we will ask you about your general health

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Do you currently smoke cigarettes? *

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How many cigarettes do you smoke per day? *

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For how many years have you smoked cigarettes? *

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Do you drink alcohol? *

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Do you use recreational drugs? *

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Quantity consumed *

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Have you used drugs intravenously or subcutaneously? *

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Do you get tired easily? *

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Do you have difficulty breathing? *

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Do you have asthma? *

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Do you use any type of respirator when sleeping? *

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Do you do any kind of exercise? *

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Specify the type, number of hours per day, frequency and number of days per week that you exercise *

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How did you hear about us? *

Google
You Tube
Tik Tok
Instagram
E-mail
Facebook
Other

Specify *

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How would you like to be contacted?

SMS( Text Message)
What's app
Phone Call
Email

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By submitting this form, I certify that the information provided to "Dr. Fredy López" is real and has not been altered in any way, as that could endanger my health.This question is required. *

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Your form entry has been saved and a unique link has been created which you can access to resume this form.

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Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Please enable JavaScript in your browser to complete this form.

- Step 1 of 111

It is important to fill out the medical questionnaire honestly and as accurate as possible to ensure you receive the premium care you deserve

This will take approximately 10-15 minutes to complete.

Complete Health Questionnaire

Once your medical coordinator reviews your health history form, your patient coordinator will be in contact with you to review pre-surgical instructions.

Start Health Questionnaire form by clicking the start button at the bottom

Pay Your Deposit to Secure Your Surgery Date

Complete your Health Questionnaire.
Pay your deposit to secure your surgery date.

Our medical team will review your application and we will work with you to achieve optimal pre-surgical health parameters.

Our patient coordinator will work with you to pick a date for your surgery.

Simply pay your deposit safely online.

* A $500 deposit is required.

* (Deposit is partially refundable on rescheduling surgery date, but not surgery cancelations).

Save and Resume Later

What's your name? *

Save and Resume Later

What's your last name? *

Save and Resume Later

have you been a patient of us before? *

Save and Resume Later

What is your biological sex? *

Male
Female

Save and Resume Later

What is your date of birth? *

Save and Resume Later

How old you? *

Save and Resume Later

What is your phone number? *

Save and Resume Later

Please provide us with a secondary phone number:

Save and Resume Later

What is your email? *

Save and Resume Later

Next we will ask you for your address:

Save and Resume Later

Please provide us with your street name and number *

Save and Resume Later

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Save and Resume Later

What procedure are you interested in? *

Gastric Bypass
Gastric Balloon
Duodenal Switch
Revision Surgery
Gastric Sleeve
SADI

Save and Resume Later

Next we will ask you for your emergency contact

Save and Resume Later

Full name of emergency contact *

Save and Resume Later

Emergency contact phone *

Save and Resume Later

Next we will ask you for details about your health

Save and Resume Later

What has been your maximum weight? *

Save and Resume Later

What is your current weight? *

Save and Resume Later

What is your height?

Save and Resume Later

Do you currently take any medication? *

Save and Resume Later

Please specify the name, reason, dose, and frequency of the medications you take *

Save and Resume Later

Do you take or have you taken any anticoagulant before? *

Save and Resume Later

Which is the reason? *

Save and Resume Later

Next we will ask you about possible allergies

Save and Resume Later

Are you allergic to penicillin? *

Save and Resume Later

Are you allergic to sulfa drugs? *

Save and Resume Later

Are you allergic to iodine? *

Save and Resume Later

Are you allergic to adhesive tape? *

Save and Resume Later

Are you allergic to latex? *

Save and Resume Later

Are you allergic to aspirin? *

Save and Resume Later

Specify any other allergies you may have

Save and Resume Later

Next we will ask you about your medical history

Save and Resume Later

Do you have or have you had an addiction?

Save and Resume Later

Specify any addictions you have or have had. *

Save and Resume Later

Do you have or have you had high lipid levels?

Save and Resume Later

Date of diagnosis of high lipid levels *

Save and Resume Later

Do you have or have you had arthritis? *

Save and Resume Later

Arthritis diagnosis date *

Save and Resume Later

What was the treatment to treat the arthritis? *

Save and Resume Later

Do you suffer or have you suffered from high cholesterol and triglycerides levels? *

Save and Resume Later

High cholesterol and triglycerides levels diagnosis date *

Save and Resume Later

What was the treatment for cholesterol and triglycerides? *

Save and Resume Later

Have you had a heart attack? *

Save and Resume Later

Date of heart attack diagnosis *

Save and Resume Later

What was the treatment for the heart attack? *

Save and Resume Later

Do you suffer from diabetes? *

Save and Resume Later

Diabetes diagnosis date *

Save and Resume Later

What is the assigned treatment for diabetes? *

Save and Resume Later

Do you suffer or have you suffered from coronary artery disease? *

Save and Resume Later

Coronary artery disease diagnosis date

Save and Resume Later

What was the treatment for coronary artery disease? *

Save and Resume Later

Do you have or have you had cancer *

Save and Resume Later

Date of cancer diagnosis? *

Save and Resume Later

What was the treatment for the cancer *

Save and Resume Later

Do you suffer or have you suffered from any liver disease? *

Save and Resume Later

Liver disease diagnosis date *

Save and Resume Later

What was the treatment? *

Save and Resume Later

Do you suffer or have you suffered from any lung disease? *

Save and Resume Later

Diagnosis date *

Save and Resume Later

What was the treatment? *

Save and Resume Later

Do you suffer or have you suffered from kidney disease? *

Save and Resume Later

Diagnosis date *

Save and Resume Later

What was the treatment? *

Save and Resume Later

Do you suffer or have you suffered from any disease of the thyroid gland? *

Save and Resume Later

Diagnosis date *

Save and Resume Later

What was the treatment? *

Save and Resume Later

Do you suffer or have you suffered from hypertension?

Save and Resume Later

Diagnosis date *

Save and Resume Later

What was the treatment? *

Save and Resume Later

Do you suffer from any other disease not mentioned above?

Save and Resume Later

Specify the name of the diseases, dates of diagnosis and treatments *

Save and Resume Later

Next we will ask you about your gynecological history

If it does not apply to you, please skip the following questions until you reach the surgical history section.

Save and Resume Later

Date of your last menstrual period

Save and Resume Later

How was the bleeding?

Strong
Normal
Light
Irregular

Save and Resume Later

Have you been pregnant?

Save and Resume Later

How many times have you been pregnant?

Save and Resume Later

Of your pregnancies, how many have required cesarean section?

Save and Resume Later

Do you take any kind of contraceptive?

Save and Resume Later

Specify the types of contraceptives you take and for how long you have taken them

Save and Resume Later

Do you currently take or have you taken any kind of hormones?

Save and Resume Later

Specify here the types of hormones and for how long you have taken them

Save and Resume Later

Are you currently pregnant?

Save and Resume Later

Next we will ask you about your surgical history

If you skipped the gynecological history questions please continue here

Save and Resume Later

Have you had any surgery before? *

Save and Resume Later

Specify the type of surgery, age, year of surgery, and complications if any *

Save and Resume Later

Have you had any complications with an anesthetic? *

Save and Resume Later

What was the complication *

Save and Resume Later

Have you had any bariatric surgery? *

Save and Resume Later

Specify the type of bariatric surgery and the year in which it was performed *

Save and Resume Later

Have you had any plastic surgery?

Save and Resume Later

Specify the type of plastic surgery and the year it was performed *

Save and Resume Later

Next we will ask you about your general health

Save and Resume Later

Do you currently smoke cigarettes? *

Save and Resume Later

How many cigarettes do you smoke per day? *

Save and Resume Later

For how many years have you smoked cigarettes? *

Save and Resume Later

Do you drink alcohol? *

Save and Resume Later

Do you use recreational drugs? *

Save and Resume Later

Quantity consumed *

Save and Resume Later

Have you used drugs intravenously or subcutaneously? *

Save and Resume Later

Do you get tired easily? *

Save and Resume Later

Do you have difficulty breathing? *

Save and Resume Later

Do you have asthma? *

Save and Resume Later

Do you use any type of respirator when sleeping? *

Save and Resume Later

Do you do any kind of exercise? *

Save and Resume Later

Specify the type, number of hours per day, frequency and number of days per week that you exercise *

Save and Resume Later

How did you hear about us? *

Google
You Tube
Tik Tok
Instagram
E-mail
Facebook
Other

Specify *

Save and Resume Later

How would you like to be contacted?

SMS( Text Message)
What's app
Phone Call
Email

Save and Resume Later

By submitting this form, I certify that the information provided to "Dr. Fredy López" is real and has not been altered in any way, as that could endanger my health.This question is required. *

Accept
I don't Accept

Save and Resume Later

Go Back

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

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If you have paid deposit then pay only the remaining amount Click here

Complete Health Questionnaire

Pay Your Deposit to Secure Your Surgery Date

Next we will ask you for your emergency contact

Next we will ask you for details about your health

Next we will ask you about possible allergies

Next we will ask you about your medical history

Next we will ask you about your general health

Complete Health Questionnaire

Pay Your Deposit to Secure Your Surgery Date

Next we will ask you for your emergency contact

Next we will ask you for details about your health

Next we will ask you about possible allergies

Next we will ask you about your medical history

Next we will ask you about your general health

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