First Name *

Last Name *

Email *

Phone Number *

City *

State / Province / Region *

Date of Birth *

Height (Feet / Inches) *

Weight (Lbs.) *

Surgery Interest? *

Any Previous Weight Loss Surgery? *

Any Previous Open Abdominal Surgery? *

Do You Have Heart Medications? *

Do You Have Heart Conditions? *

Do You Have Digestive Issues? *

Comments or Questions

I Agree to the Terms: I understand that full disclosure is necessary to my medical safety, I have filled out this medical history to the best of my knowledge, and I have answered these questions with complete honesty to insure my health and safety. I agree with Terms of Service with includes the Refund + Cancellation Policy, Privacy Policy and Disclaimer.

Pre-Screen
Health Form 2.0

Proud Partner with Mexico Bariatric Center.

Terms and conditions apply. One entry per person. Only Individuals Over 18 Years of Age are Eligible. Must be Qualified for Bariatric Surgery in Order to Be Eligible.

We will be giving out $15 Free Amazon Gift Cards to the First 35 Who Have Filled Out an Health Questionnaire Form with Mexico Bariatric Center and Get Approved. You must not have previously filled out a health questionnaire with Mexico Bariatric Center before, and not be on the schedule.

Winner also agrees to perform and consent use of their before and after pictures/photos, testimonials, video, images, and anything else we deem acceptable.

We are Offering $2,650 Credit Toward Bariatric Surgery. The winner agrees to cover the cost for the rest of the package, which includes hospital fees, surgeon fees, transportation, hotel, logistics and coordination fees. Surgery is only gastric sleeve surgery with Dr. Alejandro Guiterrez at Hospital Mi Doctor in Tijuana, Mexico.

Winner will be required to deposit $500 USD, for booking.

Additional fees, not listed, may apply. Surgery must take place within three months after the seminar and be approved by our staff. Patients must be present and fill out a health questionnaire to be eligible.

Prizes are non-transferable; no prize substitution or cash redemption allowed as provided herein.

Credit of $2,650 cannot be combined with any additional promotion, discounts, offers, or program.

Winner will be randomly selected on February 11th, 2016.

Winner is responsible for any State and /or Federal tax obligations associated with winning the prize or it’s substituted value.

Winner’s names will be made available at the conclusion of the event. SOURCiS, Inc. reserves the right to use the name and/or image of the winner in advertising or similar uses in connection with the promotion.

SOURCiS, Inc. is not responsible for accidents/damage to property or the person incurred while using undergoing the surgery.

Prizes are non-refundable and cannot be combined with any other offer.

Surgeries are at Hospital Mi Doctor in Tijuana, Baja California, Mexico.

SOURCiS, Inc. reserves the right to cancel drawing for any reason whatsoever. No transfer or prize substitution by the contest winners is allowed. All federal, state and local taxes are the sole responsibility of the winner. It is the responsibility of the winners to comply with all instructions as to the pickup, receipt, arrangements for or use of any surgery won and failure to do so in a timely manner may affect the winner’s right to claim or use the surgery. All winners and participants agree to the use of their name, voice, likeness, and city/town for advertising or trade purposes and to cooperate reasonably in any effort to promote or publicize to Mexico Bariatric Center or this contest. Apart from the prizes associated with being selected as a winner, SOURCiS, Inc. shall not be obligated to compensate you in any way for such publicity.

By attending the event you acknowledge and agree to grant SOURCiS, Inc. the right at the event to record, film, photograph, or capture your likeness in any media now available or hereafter developed and to distribute, broadcast, use, or otherwise globally to disseminate, in perpetuity, such media without any further approval from you or any payment to you. This grant to SOURCiS, Inc. includes, but is not limited to, the right to edit such media, the right to use the media alone or together with other information, and the right to allow others to use or disseminate the media.

Mexico Bariatric Center reserves the right to change, modify, or cancel this event at any time, without warning.

Bring Guest(s) to Earn $100 Gift Card: This is only eligible to former patients of Mexico Bariatric Center. If you bring guests that are approved and schedule (with $500 deposit) for bariatric surgery, you'll earn $100 visa gift card. The gift card will be given once the patient pays the $600 toward surgery.

Please enter your first and last name as it appears on your ID or license.

SPECIAL PROMOTIONS

At the seminar, the first 35 to attend and fill out a health questionnaire will receive a $15 Amazon gift card.

There will be a drawing for one winner of an EXCLUSIVE PROMOTIONAL PRICE* on their surgery at the end of this seminar exclusively for those who attend.

RSVP to confirm your spot and get your invite code.

* Terms and conditions apply, see below