Bariatric Surgery Forms

For Patients
 

Below are some of the forms that will need to be completed prior to your surgery.

Provider Acknowledgement (PDF) Please present this form to your primary care physician for signature.

Statements of Understanding (PDF)You may use this form to complete the "understanding" requirement.

Agreement Letter (PDF) This document covers a few of the keys for success. You may review, sign, and bring with you to your first clinic visit. If you have any questions we will also review this form with you in the office.

LT Medically Supervised Weight Loss Documentation (PDF) Some insurance carriers require a three or six month medically supervised diet. After we verify your insurance benefits, we will let you know if your insurance carrier has this requirement. Most often, patients will work with their primary care physician to meet this requirement. If you need to meet this requirement, this form needs to be completed by your physician at each monthly visit and returned to us.

Authorization for Release/Disclosure (PDF) Provide authorization to release your medical records.

Behavioral Health
 

Informed Consent for Therapy

Intake Form 

For Physicians
 

Weight Management Referral Form

 

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