Bariatric Surgery Discharge Form
Please complete this form to confirm your discharge and understanding of post-surgery instructions.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Bariatric Surgery Performed
*
Please Select
Gastric Bypass
Sleeve Gastrectomy
Adjustable Gastric Banding
Biliopancreatic Diversion with Duodenal Switch
Other
Surgeon's Name
*
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Instructions (Diet, Medication, Activity, Wound Care, etc.)
*
List of Prescribed Medications
Warning Signs to Watch For (e.g., fever, severe pain, vomiting, wound issues)
*
Emergency Contact Information
*
Next Follow-Up Appointment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Signature
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: