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Obesity surgery application form with our specialized surgeons Dr Patrick Noel and Dr Adala Mourad.

Bariatric Surgery Medical Form, to allow the Doctors to make an accurate medical diagnosis.

 

All your data is strictly confidential.

Prenez-vous des médicaments ? / Are you taking any medication? Required
Antécédents Médicaux / Medical History Required
Êtes-vous fumeur(se) ? / Are you a smoker? Required
Possédez-vous un passeport valide ? / Do you have a valid passport? Required

Merci ! Formulaire reçu

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