Online Application

All information submitted to Lite'N Free by our patients is strictly confidential. Lite'N Free does not share any information with third parties. The information on this application will be reviewed by our surgeon and one of our representatives will contact you soon.

First Name * Last Name * Email * Confirm Email * Phone * Address Street Street cont'd City State Zip Height * 5 6 ft. 0 1 2 3 4 5 6 7 8 9 10 11 12 in Weight * lbs Date of Birth * 01 02 03 04 05 06 07 08 09 10 11 12 / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 Gender * Male Female Do you have any of the following obesity-related conditions? Yes No type 2 diabetes (diabetes mellitus) Yes No high blood pressure, coronary artery disease or other circulatory conditions Yes No heart or vascular disease Yes No cerebral infarction Yes No gallstones Yes No gastroesophageal reflux Yes No asthma Yes No sleep apnea Yes No joint problems Yes No psychological or social disorders Do you have any of the following medical conditions? Yes No conditions related to the gastrointestinal tract (Crohn's disease, ulcers, etc.) Yes No previous gastric conditions Yes No metabolic conditions (i.e. hypothyroidism) Yes No disease that may have caused you to be overweight Yes No severe hiatal hernia Yes No Severe heart, lung or any other disease that makes you a poor candidate for surgery Yes No cirrhosis of the liver Yes No chronic pancreatitis Yes No portal hypertension Yes No autoimmune connective tissue disease Yes No need for a chronic, long-term steroid treatment Yes No addiction to alcohol or drugs   Do you have any other medical problems? Yes No Explain   Are you allergic to any medications? Yes No Specity   Are you taking any medications? Yes No Specity   Have you been overweight for more than 5 years?* Yes No Have you ever been on medically supervised weight loss programs, such as supervised diets or prescription drug therapies? Yes No   Time frame for surgery* As soon as posible 1-3 months 3-6 months more than 6 months Best time to call you* Morning Afternoon Evening Anytime How did you find about us? My Doctor A friend or relative Search Engine A link from other site Who referred you?