Medical History Form Bariatric Surgery Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number with Country CodeYour preferred method of communicationWhats AppPhoneMailCountry and City ?Procedure ?Gastric SleeveGastric SleeveGastric BypassPlastic Surgeries (Face)Plastic Surgeries ( Body)DentalHair TransplantWhich month do you prefer for your operation?( if you are considering a date, please type below)Date of BirthHeigthWeightPlease list any surgeries other surgeries you have undergone and when.Please list any medical conditions you have – Sleep apnea,heart disease, hypertension, kidney disease, cancer, diabetes, hepatitis, seizures, depression, thyroid etcDo you use any medication ?Please list any allergies to medications you have.If you are female, how many pregnancies to term have you had?Do you smoke ? if yes how many cigarettes /day ?How often you drink alcohol ?Will you come with a companion or alone ?With a CompanionAloneWhere did you hear about us ?Friend or Past PatientInstagramFacebook(Group)Google SearchIf you have a Referral Code, Please type bellowGDPRIn order to continue your journey with Ephesus Marine, we will need to process the personal information you have submitted and for this purpose, we will need to contact you via phone, email and SMS. You must accept the to continue. By clicking Submit, you agree to our Terms and Conditions and that you have read our Privacy Policy.Submit Post navigation Previous Previous post: Gastric SleeveNext Next post: Gastric Bypass