Patient Forms

Below are some of the forms that will need to be completed prior to your surgery.

Bariatric Surgery Application (PDF)—Please fill out and submit this required document  if you do not have access to the internet. Our new application process allows for patients to complete their application electronically. We will provide you instructions at the live seminar or via email or phone prior to your consultation visit.

PCP Acknowledgement (PDF) Please present this form to your primary care physician for signature. If you would like, you may bring this completed form to your first consultation visit. This will help to expedite the process.

Letter of Medical Necessity (PDF) Please provide your primary care physician with this letter as a template. Most insurances require this document for approval consideration. This form may also be completed prior to your consultation or sometime before the insurance submission date.

Statements of Understanding (PDF)You may use this form to complete the "understanding" requirement.

Agreement Letter (PDF) This document covers a few of the keys for success. You may review, sign, and bring with you to your first clinic visit. If you have any questions we will also review this form with you in the office.

LT Medically Supervised Weight Loss Documentation (PDF) Some insurance carriers require a three or six month medically supervised diet. After we verify your insurance benefits, we will let you know if your insurance carrier has this requirement. Most often, patients will work with their primary care physician to meet this requirement. If you need to meet this requirement, this form needs to be completed by your physician at each monthly visit and returned to us.