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PLEASE READ VERY IMPORTANT NOTICE TO THE RIGHT

Please fill this form completely...
First Name:
Last Name:
City:
State:
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eMail Address:
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Age:
Height:	ft.
Weight:	lbs.
Associated Pathologies: (If necessary, select more than one pathology by pressing the <Ctrl> key and clicking the left button of your mouse.)
If you suffer from other associated pathologies please fill the following field:	Other:
Previous Surgeries:
Do you drink alcohol ? :	Yes	No
	If you selected "yes", please state how often:
Do you smoke? :	Yes	No
	If you selected "yes", please state how many packs a day:
Current Medications:
How did you came about Affordable Bariatrics ?:
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