Registration Form

Eligibility criteria

Have a BMI over 40 or over 35 with associated health problems;
No unstable endocrine disease;
No psychological instability;
Understanding of the surgical procedure and acceptance of the surgical risks;
Motivation to want to change old habits and follow recommendations;
Not be addicted to drugs and alcohol.

Conversion table

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General

Health insurance number (RAMQ)

Last name *

First name *

Date of Birth *

Gender *

Address

Street number

Street name

Appartement

City

Province

Postal code

Country

Phone

Main *

Secondary

Work

Extension

Email *

Language

Calculating the body mass index

Weight (in kilograms) you can use the conversion table at the top of the page

Height (in meters) you can use the conversion table at the top of the page

Body mass index (BMI)

You must enter your weight and height in the correct format

Medical condition

Check the diseases for which you have a diagnosis *

Other diagnosis

Have you ever had weight loss surgery? *

Please select all of the bariatric surgeries you have had *

Is the purpose of this request to get an assessment for another bariatric surgery?

Date of last bariatric surgery

Location (hospital, city)

I accept the conditions*