Yes No

Do you have a Body Mass Index of 40 or greater?

Yes No

Do you have a Body Mass Index of 35 – 40 and are experiencing severe negative health effects, such as high blood pressure or diabetes, related to being severely overweight?

Yes No

Are you unable to achieve a healthy body weight for a sustained period of time, even through documented medically supervised dieting?

Yes No

Are you willing to agree with our binding patient contract?

Yes No

Are you willing to change the rest of your life?

Yes No