Patient Information

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This questionnaire will allow you and us to understand better about your suitability for the Allurion gastric balloon procedure for your health and weight loss goals. Tick the boxes if you understand and agree. Please answer honestly and to the best of your ability *

1. Do you understand that the Allurion balloon is a physical balloon that creates restrictions by reducing the capacity of your stomach?

2. Do you understand that In the first few days to a few weeks in some cases, placement of this balloon will cause you to experience nausea, vomiting, cramps, regurgitation and burping in various degrees?

3. Do you understand that the weight loss following the gastric balloon is highly variable with the company claiming an average of 10 to 15 kilos weight loss? Check www.Allurion.com for details

4. Do you understand that the above figures of weight loss are only estimates and may not necessarily apply to you?

5. Do you understand that simply having the balloon without introducing changes to your diet, sleep and exercise routines will unlikely work?

6. Are you sure that you are committed to ongoing follow-up with our team?

7. Do you understand that sometimes the body cannot tolerate this balloon and it may need to be extracted via endoscopy under anaesthesia, which will involve additional costs?

If you have answered yes to all of the above questions, then you are most likely a suitable candidate to have the gastric balloon. We encourage you to speak to our staff if you have further questions before progressing on the Allurion weight loss program.

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