Terms & Conditions
These questions are important for our surgeons to determine the best weight loss surgery option for you. Completing this form does not commit you to anything. It's simply a step to help guide you on your journey. Please fill out this form completely and accurately.
I confirm that the information I provided in this health questionnaire is true and accurate. I understand that if I am not truthful, my quote may be incorrect, and there could be serious consequences, including poor results, complications, and risks to my health. I may also face additional fees and the possibility of my surgery being canceled without a refund.
I have read and understood the Terms and Conditions of the Financial, Deposit, Cancellation, and Refund policy, and the Privacy Policy of CIBA USA. If I become a scheduled patient, I agree to these terms.
By submitting this form, I agree to receive emails, phone calls, and/or SMS from CIBA USA.