Forms

Getting Started!

Please take your time completing the attached Patient Profile, History & Physical, Dietary Info, Weight Related Illnesses and Medication forms. When you are done, please fax or mail them into our office or bring them to any one of our bariatric symposiums, along with a copy, front and back of your insurance card(s).

Once received, we will call to schedule an appointment to review this documentation with you and get you started on your path to surgery!

Patient Checklist
A check list and itemized instruction sheet on what to do after you have attended the bariatric symposium and you are ready to get started with your surgery program.

Medical History Form
A form that will help us get to know your medical history. Please fill in the blanks and circle information in the lists that pertain to you.

Dietary History and Weight-Related Conditions Form
This is a form that once completed will give us a brief overview of your dietary history and weight related illnesses or conditions.

Medication List
A blank form used to write down all the medications and vitamins you currently take.

HIPAA Consent
Consent to use or disclose patient medical information. Please complete and sign.

Demographics page
This form will tell us basic information about you including name, address, important contact information and insurance information.