The REALIZE Personalized Banding Solution requires a lifelong commitment of doing the best you can to stay healthy and active. If you feel ready to talk to your doctor about gastric band surgery, take our Eligibility Quiz first.  These same questions are likely to be asked by your doctor and your insurance company.

One or more fields below contain errors.Please correct the items noted below then re-submit the form.

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What is your age?

--choose--Under 18 years18 - 2425 - 3435 - 4445 - 5455 or older

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What is your gender?

--choose--FemaleMale

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What is your weight in pounds?

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What is your height?

--choose--4' 0"4' 1"4' 2"4' 3"4' 4"4' 5"4' 6"4' 7"4' 8"4' 9"4' 10"4' 11"5' 0"5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"6' 7"6' 8"6' 9"6' 10"6' 11"7' 0"7' 1"7' 2"7' 3"7' 4"7' 5"7' 6"7' 7"7' 8"7' 9"7' 10"7' 11"8' 0"

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Have you been diagnosed as having any of the following obesity-related conditions? (Check ALL that apply)

Type 2 Diabetes High Blood Pressure High Cholesterol Obstructive Sleep Apnea Osteoarthritis Depression Acid Reflux / GERD Stress Urinary Incontinence Polycystic Ovarian Syndrome (PCOS) or Infertility

Have you made good faith attempts at weight loss such as diet, exercise, and behavioral modification programs?

Yes No

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