Laparo Obeso Centre, Pune ::: Oxford of India :::

Family Name *	:
Middle Name / Husband Name*	:
First Name*	:
Name as in your Passport	:
Gender	:
Martial Status	:
Children
Address*	:
Zip Code	:
Place	:
Country*	:
Date of Birth *	:
Tel No. (Home)*	:
Tel No. (Work)	:
Mobile Phone	:
Email Address (Home)*	:
Email Address (Work)	:
Emergency Contact No *	:
Relationship Contact	:
Height*	:	ft inch or cms
Weight*	:
Your BMI Result *	:	(Click here to calculate your BMI)
Obesity in Family	:
Occupation	:
High Blood Pressure	:
Diabetes	:
If yes How Long	:	years
Former Operations	:
If yes what kind of operations	:
Allergic to Medication	:
If yes what kind of allergy to medication	:
Suffer for Blood Clotting	:
Allergic to iodine	:
Allergic to sticking bandings	:
Sleeping Apnoea	:
Lung Embolia	:
Cpap Machine	:
Do you Smoke	:
Did you smoked before	:
If yes when did you stopped	:
How many sigarettes per day	:
Do you have Astma	:
Do you use Inhalator	:
Do you have any kind of stomach problems	:
Do you have any kind of reflux problems	:
Do you use Aspirin	:
Use of Medication	:
Name of Medicine and Quantity	:
Use medicine for	:
Preference for Surgery	:
Surgery Date Preference	:
Do you wish to be contacted by us	:
Departure from which Airport	:
Country	:
Do you wish to stay longer in India after your surgery	:
Can we help you with longer stay	:
Destination you want to visit after your surgery	: