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Are You a Candidate for Weight Loss Surgery?
Take our 60 Second Assessment to Find Out.
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I am...
Male
Female
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Do you struggle to maintain a healthy weight using only diet and exercise?
Yes
No
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8
Do you suffer from any of these common health issues?
Select all that apply. Then select "Next."
Heartburn / Acid Reflux
High Blood Pressure
Sleep Apnea
Diabetes
Joint/Bone Issues
Depression
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Hidden field: if heartburn is selected, pass in value of 1
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Hidden field: Pass in Heartburn if value is 1 from previous question
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Hidden: Convert Height to Total Inches
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Hidden: BMI Calculator
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What is your height and weight?
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This field is required.
Enter your height and weight below.
Weight (lbs)
Height (ft)
Height (in)
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What is your biggest challenge or question right now?
*
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Select one from below.
Can I afford it?
Is surgery right for me?
Will I keep the weight off long-term?
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Which payment option describes you best?
*
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Cash / Financing
Private Insurance
Medicare
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16
Have you decided which treatment is right for you?
*
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Select one from below. If you are not sure yet, that is perfectly fine. Just select "Not Sure Yet"
Not Sure Yet
Gastric Sleeve
Gastric Bypass
Duodenal Switch
Medically Supervised Weight Loss Program
Gastric Balloon
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17
Where are you in your Weight Loss Surgery decision process?
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Step 1. Researching
Step 2. Evaluating Treatments
Step 3. Choosing my Doctor
Step 4. Ready to Book a Consult
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18
Thanks! Where can we send your results?
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Enter your information below to receive your Personalized Results. You will also receive an Email Course about your weight loss options from Texas Laparoscopic Consultants in Houston, Texas. This Assessment is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. By providing your cell phone number you agree to receive calls and texts to that number from Texas Laparoscopic Consultants.
First Name
Last Name
Email
Phone
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First Name
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Last Name
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Email
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example@example.com
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Phone
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Type your number with no parentheses or dashes
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Assessment - Date of Submission
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Date
Year
Month
Day
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