Medical History Questionnaire
For Weight Loss Surgery Patients
DO NOT COMPLETE ON A CELL PHONE
To determine whether you qualify for Bariatric Weight Loss Surgery, we ask you to fill out this Medical History Form (scroll down).
Your information is safe with us, we respect your confidentiality. Please read our Privacy Policy.
Device Requirements
1. We highly recommend using either a desktop computer or a laptop when working on the questionnaire.
2. Google Chrome browser is recommended.
3. The form is NOT designed for cell phones or tablets, the information you enter on such devices may be lost and the form will not be submitted.
PDF Format
If you are not able to use the online questionnaire form, please download a PDF format. It can be completed on a computer via a free Adobe Reader program. Please be sure to save the form once completed via a Save As feature, or print the form and complete by hand. You may return a copy of the completed form via email to info@golightbariatrics.com or fax it to 855-457-1400.
After Completion
Once we receive your completed Medical History Questionnaire for Weight Loss Surgery, we will contact you via email within 24 hours and arrange a free consultation with our surgical team via a cell phone or a video call. Your information is safe with us, we respect your confidentiality. Please read our Privacy Policy.