Contact Information

Name and Surname

e-mail adress

Adress

City

Province/State

Zip Code

Country

Private Telephone with Area Code

Office Telephone with Area Code

Fax with Area Code

Occupation

Medical Information

Date of Birth(Day/Month/Year)

Age

Height (in metres)

Weight (in kilos)

Sex

Male Female

You suffer from:

Arterial hypertension 

Type 2 diabetes 

Coronary heart disease

Lower limbs arteries disease

Lower limbs extremity venous disease

Cardiac insufficiency

Cholesterol or triglycerids alterations

Breathing difficulties

Osteoarthritis (pain and inflammation of joints)

Infertility

Gout

Acid esophagic reflux 

 Other disease:

Aditional Information

Say how your condition affects your personal / proffesional life:

How did you found out about the Obesity Surgery Centre?

  Please choose one option Doctor recommendation Patient recommendation Friend / relative recommendation Internet search Television Radio Newspaper / magazine Others

The information you have given will be kept under proffesional secret

If you wish, you can contact us throught our:
E-Mail:ccasal@intramed.net or,
by phone:(54 11) 4825-2248/4827-9109.
Also at our Center: Av. Santa Fe 2483 12° A
Capital Federal, Buenos Aires, Argentina