This contract is supported by my surgeon, and will be effective and ongoing from the initial evaluation for a laparoscopic vertical sleeve gastrectomy. The purpose of this
Contract is to outline and document that I, understand and agree to follow all the instructions, protocols and directions before and after my surgery.
Bariatric Surgery is a special opportunity for patients with obesity to improve the quality of their lives. This program is dedicated to promoting and providing this option to all. However, it has been well documented that Bariatric Surgery patients who are non compliant with medication, postoperative instructions, and outpatient follow up visits, or who otherwise do not take care of themselves, have a higher degree of complications.
I affirm that I am significantly overweight and have attempted non-surgical weight loss programs without success. The doctor has explained that obesity can cause early death and significant medical problems including but not limited to such as hypertension, diabetes, obstructive sleep apnea and high cholesterol,
Medicine is an unpredictable field. Unpredictable complications can occur. No amount of preoperative testing can assure an uncomplicated outcome. I have the responsibility to inform my doctors of any concerns, worries or possible complications at the earliest possible time. I agree that my doctors may make recommendations and I take full responsibility if I do not follow these recommendations.
I understand that significant weight loss is a life-altering event. Significant changes in eating behavior occur. I understand that every patient's experience varies and the exact prediction in my ability to cope with significant forced behavior changes cannot be predicted. I understand that my surgeon can assist in locating a mental health provider who can help me with behavioral needs.
I plan on following all post-operative visits recommended by my doctors. I plan on obtaining all tests requested by my doctors. I will abide by all nutritional supplements/recommendations that my doctors prescribe. If my surgeon's practice ever ceases to exist; I take responsibly to find an appropriate physician to monitor my life-long follow-up. If I leave the area I take responsibility in finding appropriate follow-up. I understand that proper medical follow-up requires a financial commitment that may include maintenance of health care insurance. There may be costs in the form of fees, co-payments, deductibles, lost time from work and transportation. These costs may greater than planned in the event of complications.
Support Groups: I understand that support is vital pan of my success. MidMichigan Health offers 4 meetings per month and I agree to attend these meetings on a regular basis. I am required to attend a minimum of one meeting prior to surgery. If I fail to do so, this may delay my surgery date. I also acknowledge that it is recommended that I attend a minimum of 5 meetings in the first year after surgery.
Medication problems: I understand that I will have to monitor my post-operative medication doses closely with the doctors that have prescribed them. My doctors will help if necessary. Examples of common medication problems include lightheadedness from too high a dose of high blood pressure medication and too low a blood sugar from excessive diabetic medication. I agree to work closely with my primary care doctor to regulate my medication.
Depression: I understand that it is my responsibility to seek psychological help if needed. Although most people experience improvements in their mood, some will have worsening states of depression. Weight loss is not a cure-all for all psychological problems. It is my responsibility to seek psychological help when necessary.
Smoking and other addictions: I agree and take full responsibly to quit smoking to prevent potential life threatening illnesses. Addiction to alcohol, narcotics and other illicit drugs will severely impact my health.
Return to work: I understand that although many patients can return to work within one to two weeks, some patients may require a longer recovery. My doctors are not responsible for financial difficulties due to lost work time.
B vitamin deficiencies: Deficiencies in Thiamine, Niacin, B 12 and others have been reported. These B vitamin deficiencies are very rare. Some B vitamin deficiencies can cause irreversible neurological damage, All patients are required to take a multivitamin supplement for life after this operation. Sometimes, additional B vitamin supplements are also required.
Poor weight loss and Weight Regain: Weight regain may occur, especially with "grazing" behavior. The laparoscopic vertical sleeve gastrectomy procedure is a powerful tool; however, it can be beaten. Constantly eating foods such as chips and nuts or other high calorie snacks will result in less than expected weight loss or even weight regain. High calorie liquids such as ice cream, desserts, sodas and juices may also decrease weight loss. I will take responsibility for my eating behaviors. Exercise is an excellent means to improve health and maintain weight loss. I take responsibility to increase my physical activity and will discuss with my physicians healthy methods to do so. Weight loss after a laparoscopic vertical sleeve gastrectomy is expressed as loss of a percentage of my pre-operative excess body weight. Excess weight is defined as my current weight minus my ideal body weight. On average, patients lose between 70 and 80 percent of excess weight at two years. The range of excess weight loss that nearly all patients may experience may range widely from 40% - 100%. My doctors will give me recommendations in
how to experience the most optimal weight loss. Although, the majority of patients are satisfied with their weight loss, there is no guarantee that I will achieve my goal weight. I understand that the chances of reaching my ideal body weight are low. I understand that bariatric surgery is a tool that assists with weight loss. I understand that most patients will regain some weight, and that a few can regain substantial weight. I understand that is to my responsibility to maintain healthy eating and exercise habits as prescribed by my surgeon to assist in maintenance of optimum weight loss.
Pregnancy: Women who were infertile may become fertile after their operation. I understand that I will need to use birth control to prevent unexpected pregnancies after this procedure. The risks associated with pregnancy in an obese person are generally higher than a non-obese person. There is no significant data to suggest that the risks of pregnancy are greater, either to the mother or child, after laparoscopic vertical sleeve gastrectomy surgery. I agree that before and during pregnancy, I will discuss my nutritional needs with my surgeon and obstetrician. I will always make sure that I am taking adequate vitamins and minerals throughout pregnancy and while nursing. I absolve my surgeon of any responsibility of complications of pregnancy as complications may occur with any pregnancy and there is no definitive means to prove any complication was due solely to the laparoscopic vertical sleeve gastrectomy.
I agree not to get pregnant for 12 months after a laparoscopic vertical sleeve gastrectomy. The safety of pregnancy is NOT established for patients during periods of rapid weight loss. SERIOUS, life-threatening complications may occur. I take full responsibility for birth control during this time period.
I understand that I may not be able to breast-feed during periods of rapid weight loss. If I am currently breast-feeding, I plan to wean my child before undergoing weight loss surgery.
This document has been thoroughly reviewed and explained to me, and my signature reflects my understanding of its purpose and expectations, as well as my agreement to its terms.
By signing this Contract, I agree to follow the documents guidelines and instructions and understand that failure to comply may impact the result of my surgery.