Deposit and Scheduling Form (BETA) Personal InformationName* First Last Email* Enter Email Confirm Email Phone*Age*Sex*MaleFemaleHeight (inches)*List your height in inches. (12 inches = 1ft.)Weight (lbs)*BMI (Body Mass Index)*Height (m)*Weight (kg)*Height (squared)*Medical HistoryCheck the following that apply to you: (If None, please select NONE) Acid Reflux Anemia Ankle Swelling Asthma Bipolar Bruise Easily Cancer Chest Pain Confusion Constipation Convulsions C-Pap Machine Depression Diabetes 1 Diabetes 2 Diarrhea Difficulty Swallowing Epilepsy Freq. Nausea Gallbladder Problems Glaucoma Headaches Heart Disease Hypertension Indigestion Liver Problems Lower Back Pain Lung Problems Painful Urination Paralysis Pneumonia Pregnant Seasonal Allergies Shortness of Breath Sleep Apnea Sore Throat Tuberculosis Ulcers Vomiting NONE Please explain your medical conditions listed above (if None, please enter NONE)*Please describe any health issues not addressed above (If None, write NONE)*Do you have any cardiac issues?*NoYesHave you in the past, or currently have cardiac issues?If yes, can you get a Cardiac clearance letter from your Doctor?*NoYesDo you currently smoke?*NoYesDo you currently smoke cigarettes or cigars?WARNING! You must stop smoking 2 weeks prior to surgery up until 4 weeks after the surgery.Do you currently have symptoms of Heart Burn and/or Acid Reflux?*YesNoWARNING! An additional cost of $500 is a hernia is discovered.Are you currently prescribed any pain medications?*YesNoWARNING! You must bring your own pain medication for your surgery.Do you currently use a CPAP Machine?*YesNoWARNING! You must bring your own CPAP machine or there will be an extra charge.Emergency ContactsName* First Last Phone*Name* First Last Phone*Please Choose Your Desired Surgery Dates1st Desired Date* 2nd Desired Date* 3rd Desired Date* Deposit InformationSecurity Deposit Refund Policy: (1) Fully refundable before the day of surgery for any reason. (2) On the day of surgery If surgery is canceled for any reason. The patient is responsible for any hospital fees and costs. The patient will be provided an itemized invoice, and expenses will be deducted from Security Deposit. (3) After surgery, if a hiatal hernia is repaired during surgery, photo and video evidence will be provided to patient and security deposit will be applied to the cost of hernia repair. Otherwise, the security deposit will be returned within 7 to 10 days post op in the manner it was received.Surgery Deposit Price: $500.00 Total $0.00 NameThis field is for validation purposes and should be left unchanged.