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Please answer all questions.

* Indicates required information
By selecting this box, I certify that I have watched the entire Missouri Bariatric Services online video seminar. 
By selecting this box, I certify that I acknowledge and understand that in order to be seen at a new patient appointment, a completed and signed Primary Care Physician Referral Form is required.  
In addition, I certify that I will bring in a completed new patient packet to my first appointment. 
First Name * 
Last Name * 
Date of Birth *    (mm/dd/yyyy)
Address * 
City * 
State * 
Zip Code * 
Email Address 
Phone Number 1 * 
Phone Number 2 
Primary Insurance * 



Secondary Insurance * 




How did you hear about our program?  * 





If Other, please specify:

To qualify for bariatric surgery, you must:  * 



Diagnostic tests may be required prior to surgery to assess your health and make sure you are safe to undergo weight loss surgery. * 

You are required to complete a psychiatric evaluation before surgery. A psychiatric evaluation can only be performed by: * 



Before surgery you will be required to: * 



Adjustable gastric banding involves the placement of a prosthetic device around the upper portion of the stomach that restricts food intake. In order to be successful with adjustable gastric banding, you need: * 


You are at an increased risk for complications after weight loss surgery if: * 



You are required to stop smoking three months before surgery and remain smoke-free for life. * 

If you have a BMI greater than 60 you will be required to lose weight to become a candidate for weight loss surgery. * 

What is the most important nutrient at a meal after surgery? * 


After surgery it is acceptable to drink carbonated beverages, such as regular or diet soda and beer. * 

After surgery, specially-designed bariatric vitamin and mineral supplements are required for how long? These supplements are not paid for by insurance. * 



Follow up is required 1 week, 1 month, 3 months, and annually for 5 years after surgery. * 

 



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