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  • About SWLC
    • Reasons to Choose Us
    • Meet Our Team
    • We Understand Obesity
    • Patient Consultation Video
    • Long Distance Patient Care
    • Available Financing
  • Lap-Band
    • Am I A Candidate?
    • How Lapband Works?
    • Lap-Band Consultation Video
    • Lapband Advantages
    • Potential Risks
    • What is Continued Support?
    • How Will I Look?
    • Lap-Band FAQs
  • Gastric Balloon
    • Am I A Candidate?
    • How Gastric Balloon Works?
    • Gastric Balloon Advantages
    • Potential Risks
    • What is Continued Support?
    • How Will I Look?
    • Gastric Balloon FAQs
  • Message Forum
    • Welcome To SWLC Forum
    • Lap-Band Discussion
    • Private Members
    • Gastric Balloon Discussion
    • SWLC Question And Answer
  • SWLC Blog
    • Diabetes Treatment
    • Diet & Nutrition
    • Exercise & Fitness
    • Gastric Balloon
    • Lap-Band
    • News From SWLC
    • Recent Studies, News Stories
    • Upcoming Events
    • Future Seminars
    • WINGS Newsletter
  • Resources
    • Lap-Band Connect™
    • SWLC Patients
    • Healthcare Professional
    • BMI Calculator
    • Video Gallery
    • Media Kit
  • Contact Us
    • Make an Inquiry
    • Patient Questionnaire
    • Directions To SWLC
Get a FREE consultation with one of our surgeons

Contact Us

  • Make an Inquiry
  • Patient Questionnaire
  • Directions

Surgical Weight Loss Centre Locations

Mississauga
1413 Hurontario St.
Mississauga, ON L5G 3H5

Toronto
c/o Miracle 10 Boutique
67 Scollard Street
Toronto, ON M5R 1G4

Calgary
c/o Suitor House
1004 8th Street SE
Calgary, AB T2G 0M4

Vancouver
c/o Cambie Surgery Centre
2836 Ash Street
Vancouver, BC V5Z 3C6

Phone: 905-278-8000
Toll-Free: 888-278-1582
Fax: 905-275-1582
Email: info@swlc.ca

Information seminars

Sign up for a great opportunity to meet our surgeons and learn more about the Lap-Band and Gastric Balloon programs during a free information seminar. All seminars are held on every last Wednesday of the month with our featured surgeon from 5:30pm – 6:30pm. To reserve your spot, click here.



Quick Links

SWLC programs

The Lap-Band and Gastric Balloon Programs include a weight loss procedure and provide education and support to help you modify eating and lifestyle behaviours for sustained weight loss.

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Long distance patient care

Programs have been adapted to meet the special needs of our out-of-province and long distance patients.

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Get to know our team

Our team consists of certified weight loss specialists, including three surgeons, nurses, dietitians, patient coordinators and French-speaking staff.

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SWLC Video Gallery

SWLC Patient Questionnaire

We’re pleased to meet you

Whether your scheduled consultation with one of our surgeons is in person or by telephone, this questionnaire must be completed and submitted beforehand. Your surgeon will read the Patient Questionnaire prior to the consultation in order to familiarize himself with your unique medical history and personal situation. If you have not yet scheduled your appointment, please call the clinic at 1-888-304-5155. All information will be kept strictly confidential.

 

PERSONAL DETAILS
*Indicates mandatory field
*Title
*Surname
*Given Names
*Address
*City
*Postal Code
*Telephone (Home)
Bus
Cell
*Email
Date of Birth
*Age
Occupation
Marital Status
How did you first hear about SWLC?
Please describe
Family Doctor
Address
City
Postal Code
*Height
 Feet  Inches
*Weight Pounds
BMI (Body Mass Index)
Are you a member of a Health Benefits Plan?
Yes No If so, name of company:
 
PREVIOUS WEIGHT LOSS HISTORY
Weight Watchers
Date(s)  Duration: Amt. Weight Lost:
Jenny Craig
Date(s)  Duration Amt. Weight Lost:
Dr. Bernstein
Date(s)  Duration Amt. Weight Lost:
           
Others (please describe)
What exercise do you do on a regular basis?
When did you first start to have problems with your weight (age)?
Were there any life events that lead to significant weight gain?
For how many years would you describe yourself as overweight/obese?
 
PERSONAL MEDICAL HISTORY
Diabetes Yes No Details:
Respiratory/ Breathing problems Yes No Details:
Kidney or urinary disorder Yes No Details:
Gallstones Yes No Details:
Hepatitis or liver disease Yes No Details:
High blood pressure Yes No Details:
Heart disease Yes No Details:
Thrombosis or clotting disorder Yes No Details:
High cholesterol Yes No Details:
Anorexia / Bullemia Yes No Details:
Depression Yes No Details:
Psychiatric Disorder Yes No Details:
Sleep Apnea Yes No Details:
Heartburn or Hiatus Hernia Yes No Details:
Do you drink Alcohol or Beer Amount Weekly:
Do you smoke cigarettes?
Yes No
If yes, How many per day?
Allergies:
Please give details of previous surgery and major illnesses :
Please list any other medications that you are currently using:
Other substance use (current or in the past)
Yes No Details:
Have you ever been hospitalized for psychiatric reasons?
Yes No Details:
 
Weight Loss Goals
What is your desired weight? lbs
Which program are you interested in, Lap-Band or Gastric Balloon?
Please tell us why you think this program is right for you?
Are you ready to make lifestyle changes to achieve sustained weight loss?
Do you have any questions regarding the programs we offer?
If you are having trouble completing or sending this form, please contact us toll free at 1-888-304-5155 and we will be happy to help.
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