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You will receive a customized quote within three business days!

First Name

Last Name

Email

Phone

Date of Birth

Weight

Height

Tentative Travel Date

City & State

Promo Code

Do you have a valid Passport?

Yes

No

Payment Option

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Getting Quotes

Would you be traveling alone?

Yes

No

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness, allergies or injury?

No

Yes

How many pregnancies have you had?

0

1+

3+

Do you smoke?

No

Yes

How many surgeries have you had?

0

1+

3+

If you answered Yes to any question, please elaborate on surgeries, conditions and hospitalizations. Please write N/A if you answered No

What procedures are you interested in?

Gastric Sleeve

Gastric Bypass

Add-Ons

Cosmetic Procedure (Please specify in the comments section)

Dental Procedure (Please specify in the comments section)

Compression Girdle (Faja)

Body Contouring Massages (Atlanta)

Tourism- Bogota City Tour

Tourism- Salt Cathedral of Zipaquirá and Nemocón mine

Tourism- Villa de Leyva Tour

Tourism- Coffee Farm

Other (Please specify in the comments section)

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Questions & Comments

I declare that the info I’ve provided is accurate & complete. I read & agree to the Medical Release Authorization TermsView terms

By submitting this form, you consent to My Body by Design LLC and the clinic's medical team to use of your data contained in this questionnaire for purposes limited to medical use only. My Body by Design LLC takes no responsibility if you provide false information or conceal your entire medical history. I understand that my personal information will be treated separately and confidentially. I declare that the info I’ve provided is accurate & complete

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