Bariatric Surgery Eligibility Form

Start Your Journey Toward a Healthier Life

Answer a few quick questions to see if you qualify for weight-loss surgery. You'll get:

A treatment plan
A price quote
Next-step guidance

Results within 48 hours.

Personal Information

First name

Last name

Please indicate your gender:

Female

Male

Other

Email

Phone

Body Measurements

Your Body Mass Index (BMI) will be calculated automatically based on this information.

Height (ft)

Weight (lbs)

Medical History

Please share your current medical background. This helps our doctors understand your health profile before recommending a treatment plan.

By submitting this form, I consent to the collection and secure processing of my personal and medical information in accordance with Maple Med Global’s Privacy Policy and Terms of Use.