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Citizens Bariatric Center Citizens Bariatric Center

1-800-555-1555
361-574-1738
2701 Hospital Drive
Victoria, Texas 77901
email us

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?

Gastric Bypass Lap Band

How did you hear about Citizens Bariatric Center?

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?
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?
No
If Yes, List Physicians and Approximate Dates:
   
3. Do you take any medications?
No
If Yes, List All Medications with Dosage:
   
4. Have you ever had any surgery?
No
If Yes, List Surgery Type and Approximate Dates:
   
5. Do you smoke tobacco?
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?
No
If Yes, How Many Drinks (per Day/Week/Month):
   
7. Have you ever abused drugs or prescription medications?
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.

 

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