New patient referral form

 

All new patients are required to attend a free new patient informational seminar. Team:Bariatrics will contact the patient within 24 hours to schedule the seminar. The initial consult will be scheduled at the seminar. Attending the seminar ensures patient understanding and commitment to the lifestyle changes needed to be successful in the Team:Bariatrics programs. Please fill this form out completely for your patient to receive the best service.

 

New Patient Referral Form
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Patient Health History

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This field is mandatory.

BMI is calculated by (weight/height * height)

Patient Medical History/Co-morbidities (please check all that apply)

Provider Information

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CONFIDENTIALITY NOTICE: The documents accompanying this telecopy transmission may contain confidential information. The information is intended only for the use of the individual(s) or entity named above. If you are not the intended recipient, you are notified that any disclosure, copying, distribution or the taking of any action in reliance on the contents of this telecopy information is not permissible. If you have received this telecopy in error, please immediately notify us by telephone at the above number and then destroy the telecopy information. Thank you.