Bariatric Surgery Appointment Pre-screening Form
Complete this Bariatric Surgery Appointment Pre-screening Form to help us determine your readiness for a bariatric surgery appointment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Height (in cm or inches)
*
Weight (in kg or lbs)
*
Preferred Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What is your main goal or reason for considering bariatric surgery?
*
Please describe any prior weight-loss attempts
*
List your current medications
*
Do you have any relevant medical conditions? (e.g., diabetes, hypertension, sleep apnea)
*
Additional notes or concerns
Submit Pre-screening Form
Should be Empty: