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Weight Loss Candidate Form

Home » Weight Loss Candidate Form

Are You a Candidate for Our Program?

Take our 60 Second Assessment to Find Out.

Step 1 of 9

0%

I am...*
- Male
- Female

Have you tried diet and exercise programs without durable success?
- Yes
- No

Do you suffer from any of these health issues?*
- Heartburn / Acid Reflux
- Sleep Apnea
- Joint Issues
- High Blood Pressure
- Diabetes
- Heart Disease
- None

What is your height and weight?
Height (ft)
Height (in)
Weight (lbs)?

What Major Concerns Do you have*
- Can I afford it?
- Is Surgery right for me?
- Safety of Surgery?
- Will I keep the weight off in the long-term?
- Other concern?
- No concerns

Which treatment is right for you?*
- Medically Supervised Weight Loss
- Endoscopic Sleeve Gastroplasty or Gastric Balloon
- Gastric Sleeve
- Gastric Bypass
- Duodenal Switch
- Bariatric Surgery Revision
- Not Sure at this time

Enter your information below to receive your Personalized Results
Name*
First Name Last Name
Email*
Phone*

What is your BMI?*
- Over 30 (kg/m2)
- Under 30 (kg/m2)
Based on the provided information, you likely do qualify for our program, would you like to send your information to our office?*
- Yes
- No
Your BMI (ratio of weight and height) are currently too low for our Weight Loss program. Would you like someone from the office to call you?*
- Yes
- No

Thank you, your information has been sent to the office
Thank you, someone will be reaching out to you.
Thank you for taking our 60 second assessment
Would you like a FREE insurance verification for weight loss services?*
- Yes
- No
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About Us
Minimally Invasive General Surgery Dallas, Fort Worth
Weight Loss Surgery Dallas, Fort Worth
Non-Surgical Weight Loss Treatment Dallas, Fort Worth
Anti-Reflux Surgery Dallas, Fort Worth

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Contact Us

Sachin S. Kukreja, MD FACS FASMBS
Elizabeth A. Hooper, MD FACS FASMBS
DFW Bariatrics and General Surgery

1411 N. Beckley Avenue
Pavilion 3, Suite 454
Dallas, TX 75203

Tel : 469-620-0222
Fax : 469-620-0223
E-mail : [email protected]

Sachin Kukreja, MD

Sachin Kukreja, MD

4.9

Elizabeth Hooper, MD

4.9

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Now DFW Bariatrics and General Surgery, formerly known as Sachin Kukreja, MD.

© DFW Bariatrics and General Surgery, Dallas, TX 2021

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