Forms for Patients


Weight-loss surgery is complex, and is only one step in a long process. We make every effort to expedite this process for you. We ask that you fill out the forms on this site in as much detail as you can, so we can help you achieve your health goals.

In this section, you’ll find the forms needed for your Initial and Pre-Op Visits. Also, this is where you’ll find information on Diet and, under Miscellaneous Forms, our Patient Handbook on Exercise. These are important components in achieving and sustaining successful weight-loss after surgery.

Your health goals are important to us. We look forward to working with you to achieve them.

Initial Visit

  • Registration Form
  • Initial Evaluation Form
  • Records Release Authorization
  • Insurance Authorization
  • GERD-HRQL Scale (Gastroesophageal Reflux Disease)


  • Pre-Op Visit
  • Patient Contract

  •      Lap-Band Patients
  • Proxy Form
  • Procedure Review Quiz
  • Consent Form

  •      Open RNY Gastric Bypass Patients
  • Proxy Form
  • Procedure Review Quiz
  • Consent Form

  •      Lap RNY Gastric Bypass Patients
  • Proxy Form
  • Procedure Review Quiz
  • Consent Form


  • Diet
  • Lap-Band Patients Diet
  • RNY Gastric Bypass Patients Diet
  • Lap RNY Gastric Bypass Patients Diet


  • Miscellaneous Forms
  • Patient Handbook-EXERCISE







  • © 2007 Nicole B. White, MD
    Contact Us at (206) 368-1230