Citizens Bariatric Center Online Patient Application

Please complete the form below. Your information will be reviewed to determine eligibility for surgery and someone will contact you. A preliminary investigation into insured benefits for weight loss surgery may also be done as a courtesy to you.

Please contact Nanette Berger, Bariatric Coordinator if you have any questions (361) 574.1738

Which surgery are you interested in? I'm not sure Gastric Bypass Lap Band

How did you hear about Citizens Bariatric Center? Internet Search TV Commercial Newspaper Ad Billboard Ad Phone Book Listing Support Group A Friend Physician Referral Other If Other Please Explain:

Patient Information: Patient Name:     Mailing Address: City: State: +Zip: Home Phone: Work Phone: Cell Phone: Email Address:     Birthdate (M/D/Y): +Age: Sex:

Insurance Information: Primary Insurance (if None please indicate None in first line) Insurance Company: Mailing Address: City: State: +Zip: Phone: Policy Holder: Group Number: Policy Number: Employer:   Secondary Insurance Insurance Company: Mailing Address: City: State: +Zip: Phone: Policy Holder: Group Number: Policy Number: Employer:

Health Questionnaire: 1. Have you ever had any previous obesity surgery? Yes No If Yes, What Type of Surgery: When did You have the Surgery: Who was the Surgeon or Institution:     2. Have you received physician supervised treatment for obesity? Yes No If Yes, List Physicians and Approximate Dates:     3. Do you take any medications? Yes No If Yes, List All Medications with Dosage:     4. Have you ever had any surgery? Yes No If Yes, List Surgery Type and Approximate Dates:     5. Do you smoke tobacco? Yes No If Yes, How Many Packs per Day: What Age Did You Start Smoking: If Previously a Smoker, When Did You Quit:     6. Do you drink alcohol? Yes No If Yes, How Many Drinks (per Day/Week/Month):     7. Have you ever abused drugs or prescription medications? Yes No If Yes, Are You in a Recovery Program:

Medical History: Patient Height: feet + inches Patient Weight: lbs     Check all (any) of the following conditions that you have: Diabetes Mellitus +If Yes, how long? years Hypertension (High Blood Pressure) Joint Pain (Arthritis) In Feet, Knees or Hips Low Back Pain Sleep Apnea (Stop Breathing During Sleep) Gastroesophageal Reflux (Heartburn) Urinary Stress Incontinence Asthma Gallbladder Attacks (leave unchecked if your gallbladder has been removed) Congestive Heart Failure Heart Attack or Coronary Disease or Angina Depression Anorexia or Bulemia Infertility (Females of Child Bearing Age) High Cholesterol or High Triglycerides Lower Extremity Swelling Shortness of Breath Upon Exertion None of the Above

Please review your information before pressing submit. Thank you for your time.