Submit this form ONLY after deposit has been received.


Patient Coordination Checklist:


1. Check pricing matches:

✓ Procedure type

✓ BMI (High BMI = >49.4, Double = >59.4)

✓ Doctor

✓ Extras (i.e. Revision, Endoscopy w/LapBand Removal, Latex, Financing Fee, Pain Meds, and etc.)


2. Check availability calendar:

✓ Hospital Shows Open (SER shows an opening or Obesity does not show Closed)

✓ Doc does not show Closed


3. Confirm patient can see Doc selected (i.e. Cardiac=Perez/Green only, Cueva no High BMI/Major Contraindications)


4. Must double check for accuracy:

✓ Amounts

✓ Dates

✓ Deposit notes (if different name or method note)

✓ Travel Requirements


5. Please double check pre-op requirements and diet length are checked on AC chart.


Patient Booking Submission
Patient Gender*
Extras Fees (click each that apply)
Sharing Hospital (check if sharing)
Companion
Hotel/Travel Requirements