This is the OFFICIAL Health Questionnaire Form of Mexico Bariatric Center.

Providing false, incomplete, or misleading information about your medical history could have very serious consequences that may put yourself at risk for severe complications both during or after bariatric surgery. Your health questionnaire remains completely confidential between your surgeon and their medical support team.

Please fill out the entire page, and make sure to electronically sign at the bottom.

Warning! Please read carefully, so we can get an accurate picture of your health.

Your BMI calculation here is only for reference.Your BMI will be verified in Mexico, right before surgery.

Current Medications: Include all medications.

Medication
How Long
Dose
How Often
Purpose

 

Illness History: Include all illnesses.

Illness
Date
Treatment
Outcome

 

Previous Surgeries: Include all previous surgeries.

Surgery
Date
Reason
Open or Laparoscopic

Detailed Health History

Auto-Immune System:

Cardiac System:

Circulatory System:

Endocrine System:

Hepatic System:

Digestive Problems:

Diet History:

Tobacco and Alcohol Usage:

Review of Systems

Do you currently suffer from any of the following symptoms?

Symptom
How Long?
What Treatments?

Is there anything related to your medical history that has not been covered? Please indicate below:

Do you have any questions for your surgeon or medical team? Please indicate below:

1. All information that you are required to provide with this Health Questionnaire as well as any other medical information thereafter is required to be truthful, complete, and accurate. If any information in the Health Questionnaire is not truthful, complete or accurate then the surgeon will cancel your surgery and can in the loss of your security deposit, credit deposit, and all monies paid for surgery.

2. It is imperative that the height and weight reported on the Health Questionnaire be accurate. ALL patients are weighed and measured before surgery. If the BMI (Body Mass Index) at the time of surgery does not accurately reflect the height and weight reported on the Health Questionnaire, the surgeons(s) may exercise their right to forego the surgical procedure and any deposit made will be forfeited. If the doctor(s) decide to proceed with surgery, there may be additional charges due to the revised BMI. Be aware that these charges would be determined by you and your doctor(s) at the time of the Pre-Op appointment and must be made payable to the doctor(s) before surgery is performed.

1. I agree to the Deposit, Refund and Cancellation Policy. A deposit of $500 (U.S. Dollars) must be made on the day of scheduling your surgery date. If you make a deposit via wire transfer or direct deposit, please fax a copy of the wire transfer or the direct deposit receipt with your name on it to 1-855-453-2329 to ensure proper credit. The deposit made is governed by our Deposit, Refund and Cancellation Policy.

Deposit and Booking Surgery:

  1. Security Deposit: A minimum of $500 USD security deposit is due at the time of scheduling the surgery to secure your date.
  2. Remaining Balance Deposit: Fifteen (15) days prior to surgery, the client needs to pay the entire remaining balance of the surgery. Patients are required to have a zero balance prior to travel to Mexico. If canceling or postponing the surgery the remaining balance deposit will be governed by our refund and cancellation policy (found below).

Refunds and Cancellation Policy: Security Deposit & Remaining Balance Deposit

Due to the preparation costs, (i.e., hotel reservations, booking time and hospital room, scheduling transportation, nutritional consultation, scheduling of hospital staff, supplies ordered based on surgery schedule, etc.), all refunds will be handled based on the following criteria:

  1. If surgery is CANCELLED due to a medical condition discovered during the pre-operative period or if it is determined that the operation cannot proceed due to safety reasons, a full refund of the security deposit will be provided minus any costs incurred by Mexico Bariatric Center, including but not limited to transportation, hotel accommodations, pre-op test(s), doctor fees, processing fee ($25.00) nutritional consultation ($150.00), etc.
  2. If surgery is POSTPONED due to a medical condition discovered during the pre-operative period, a full credit of the security deposit will be applied towards subsequent surgery minus any costs incurred by Mexico Bariatric Center, including but not limited to transportation, hotel accommodations, pre-operative test(s), doctor fees, etc.
  3. If the client cancels the surgery within 15 days or less before the ORIGINAL surgery date then 30% of the surgical fees (including the security deposit and remaining balance deposit) will be forfeited.
  4. If the client cancels the surgery, for any reason, less than 30 days before the ORIGINAL surgery date, this will result in the loss of the entire amount of the security deposit all rules and policies apply to the original scheduled time.
  5. If the client cancels the surgery with 31 to 45 days before the ORIGINAL surgery date then a 60% refund of the security deposit will be provided minus any costs incurred by Mexico Bariatric Center, including but not limited to transportation, hotel accommodations, pre-op test(s), doctor fees, processing fee ($25.00) nutritional consultation ($150.00), etc.
  6. If the client cancels the surgery with 46 days or more before the ORIGINAL surgery date then a full refund of the security deposit will be provided minus any costs incurred by Mexico Bariatric Center, including but not limited to transportation, hotel accommodations, pre-op test(s), doctor fees, processing fee ($25.00) nutritional consultation ($150.00), etc.
  7. If surgery is canceled because the patient failed to follow the pre-operative instructions given by the medical staff this will result in the loss of the entire amount of the security deposit and remaining balance deposit.
  8. If surgery is rescheduled, all cancellation rules and policies apply to the ORIGINAL scheduled date.
  9. All cancellations must be received by Mexico Bariatric Center in writing, via email or fax.
  10. Please allow 6 to 8 weeks for processing refunds.
  11. In the event that collections are necessary, the cost/fees incurred by SOURCiS, Inc. (dba Mexico Bariatirc Center) will be applied to your balance owed.

1. Canadian clients will need to make the final payment using traveler's check, credit card, bank draft or by some other guaranteed form of payment and must be made in U.S. Dollars.

200 C-PAP machine (Please bring your own if needed)
450 BMI 49 and above
950 BMI 59 and above
1,350 BMI 69 and above
1,950 BMI 79 and above
650 Revision of Previous Weight Loss Surgery (Except Bypass Surgery)
1,400 Revision of Previous RNY (Gastric Bypass) Surgery
950 Revision of Previous Plication (Gastric Plication) Surgery
400 Endoscopy
500 Hiatal Hernia Repair
1,400 Previous Reflux / Fundoplication
1,500 Umbilical Hernia Repair
250 Pain Pump per night
250 Private Nurse per night
400 Additional night in Hospital per night
116 - 179 Additional night in Hotel (depending upon season) per night
540 Additional charge for 2nd companion (Sleeve)
670 Additional charge for 2nd companion (RNY/DS)
25 Cash for the driver on the way in
15 Additional Special Menu card if misplaced
25 Additional T-shirt

* Additional charges may also apply for patients with certain medical conditions and/or for procedures not included in the initial surgical procedure (i.e.; gallbladder removal, etc.)

Prices subject to change without notice. All fees stated include a cash discount.
A 5% additional fee is required for credit card payments. (Visa, MasterCard, & Discover)


By Signing Electronically You Agree to the Terms: I understand that full disclosure is necessary to my medical safety. I am acknowledging that I have provided all of my personal and medical history through this form and I am interested in having bariatric surgery with Mexico bariatric Center. I have filled out this medical history to the best of my knowledge, and I have answered these questions with complete honesty to ensure my health and safety. I agree with the Terms of Service which includes: Deposit, Refund, and Cancellation Policy, Privacy Policy, and Disclaimer. I understand that SOURCiS, Inc. (DBA: Mexico Bariatric Center) is a surgery facilitator and not a healthcare provider.

We Respect Your Privacy and Confidentiality. We'll never sell or divulge your information to any 3rd party. Your information will only be released on a strictly need-to-know basis, with your prior approval first. You also agree to be followed up with our coordination team via email, phone, and occasional text messages.