Obesity Surgery Center - Dr. Roberto Rumbaut

The best solution to your weight problem may be gastric bypass surgery or the adjustable gastric band. Throughout the US, Canada and Latin America, people suffering from severe obesity are finding a long-term solution with Dr. Rumbaut. To begin the process of determining if weight loss surgery, whether the adjustable gastric band or gastric bypass, is the most appropriate course of action for your particular circumstances, please fill out and submit the form below.

PLEASE NOTE: The United States State Department is changing its rules regarding international travel. As of December 31, 2006, you will only be able to use a passport for traveling to Mexico. Please plan ahead for your trip!

*required fields for those interested in the lapband and the gastric bypass surgical procedures
*First Name:**
*Last Name:**
*E-mail:**
*Confirm E-mail:**
*Address:**
*City:**
*State/Province:**
*Zip:**
*Country:**
*Date of Birth:**
*Sex:**
*Language:**
*Phone Number:**
*Surgery:**
*Height:**	ft in OR m cm
*Weight:**	lb OR kg
Occupation:

Family Obesity History
Parent:
Sibling:

Medical History Choose all that apply in each category. To select multiple options use the CTRL key.
Cardiovascular:
Respiratory:
Gastrointestinal:
Dentures:
Gynecological:
Endocrine:
Psycho/Social:
Joint Pain:
Arthrosis:
Other Diseases:
Other Diseases (list):
Drugs:
Alcohol drinks/day:
Medications Prescribed:
Medications Self-Administered:
Allergies - Food:
Allergies - Medicine:

Diet History
Previous Diets:
When:
Weight Loss:
Weight Regained:

Timeframe for Surgery:
Financing Interest:
How did you hear about us?:
Other Information:

First Name:
Last Name:
Email:
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Phone:
Message:

MedChoice Financial MedChoice Offers: • Credit Limits from $500 to $25,000* • Low Monthly Payments • No Pre-Payment Penalties • No Annual Fees • No Payments or Interest Plans for 3, 6 or 12 Months! • Online Account Info & Bill Pay • Authorized User Feature which allows your Family or Friends to use the Account without having to Reapply To maximize ALL approval options for your treatment please complete the follow steps: 1. Call 800.358.8980 (Option 1). 2. Identify Provider Id # 4618 or Provider Name - Dr. Roberto Rumbaut 3. Receive an answer within minutes

Centro Medico Metropolitano
Av. Del Hospital No. 110 – 104
Colonia Sertoma
Monterrey, NL, Mexico, 64710
Tel: (52-81) 8347-4481 or
(52-81) 8333-6891
Fax: (52-81) 8347-4481