Forms for Patients

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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