• Bariatric new patient

  • Patient Information

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  • Bariatric Surgery Program

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  • Additional Information

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  • Medication List

    Please list all medications as well as the dose, frequency, and the reason why you are taking it.
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  • Please fill this form out to the best of your ability. We must have this information to best help you with your weight management goals. None of the information will ever be used in a negative or judgmental way but as a tool to personalize care to fit your individual needs. This, like all of your medical records, is kept confidential.

  • Weight History

  • Previous Weight Loss Attempts

  • What would you like to weigh in:
    6 months   *   
    1 year   *   

  • Diet History

  • Write down a typical day of eating in the box below.

    Include drinks, condiments, snacks, and full meals. Also include portion sizes.
  • EXERCISE

  • Mental Health History

  • Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully, and check your response

  • Social History

  • Consent to Share Medical Information

  • On this date, I, * , do hereby grant permission for my physician or his/her staff to discuss information regarding any and all treatment results to:

  • Notice of Privacy Practices

  • Financial Policy

  • The undersigned Patient or legally authorized representative ("Agent") of the Patient acknowledges that he or she personally received a copy of the Great Lakes Surgical Associates Notice of Privacy Practices on the date indicated below.

  • All Patients: Authorization to Release Information & Assignment of Benefits

    I authorize the release of any medical information necessary to process my medical service claims. I permit a copy of this authorization to be used in place of the original. I hereby authorize Great Lakes Surgical Associates (GLSA) to apply for benefits on my behalf for covered services rendered by my physician. I request that payments from my insurance company be made directly to GLSA. I certify that the information I have reported regarding my insurance coverage is correct. I understand I can revoke this authorization at any time by submitting a written request. I hereby state that all the above information is valid and accurate to the best of my knowledge.

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  • Information about Agent (attach appropriate documentation):

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