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New Bariatric Patient Documents

Bariatric New Patient Questionnaire

Read below to SAVE UP TO $125.00!

 

All patients actively seeking weight-loss-surgery are required to bring this completed questionnaire to their initial consultation with our dietitian.  

 

Do not leave sections blank, if none or not applicable indicate so in that section.  Failure to bring questionnaire and forms completed to your consultation will result in the dietitians need to reschedule your consultation for a later date, as this paperwork is necessary to complete your assessment and enable the hospital to bill your insurance.  All appointments are subject to availability.  We need the full duration of your appointment to properly assess you as a surgical candidate so please bring paperwork completed to avoid additional out of pocket expenses, rescheduling and surgical delay.

 

There will be a $5.00 out-of-pocket fee for us to print the document at your appointment and you will be required to stay AFTER your consultation to complete and turn in before you leave the office.  If new nutrition concerns are identified after we receive your questionnaire you may be asked to schedule a follow-up, during clinic hours, with our dietitians, at your own out-of-pocket expense.  Follow-up services range from $35-$125. 

This questionnaire takes approximately 20-30 minutes or more to complete.  The document is available in two formats in MS Word Template format.  This means you can download, type in your responses, save and fax to 443-490-5060 or email using our contact form on this site, no less than 48 business hours prior to your consultation.  We also have a printable version and you can bring completed to your consultation.  

See description above to save!

Bariatric New Patient Forms

This forms packet includes documents required by our office for surgical clearance.  It includes documents such as our financial policy, authorization to release your chart to your surgeon/family/doctors, agreement regarding our materials, etc. Please bring signed forms to your initial consultation.  You may also fax them to 443-490-5060 or email using our contact form on this website NO LESS than 48 business hours prior to your consultation.  Failure to complete these documents will delay our ability to clear you for surgery. 

GIBNC Bariatric Program Services

Services included in our Bariatric Nutrition Education Program. 

Doctor or Dietitian Supervised Weight-Loss Documentation

Most insurance companies require anywhere from 3-6 consecutive months of supervised weight loss documentation.  To determine the requirements of your insurer please contact your surgical coordinator at your surgeon's office.  

 

Why use GIBNC? Our documentation includes 30-40 minutes of support group style education that feeds off our long-term education.  This format offers ongoing support from other patients as well as the dietitian teaching.  We emphasize preparing for what you will be doing long term and eating normally.  We will help you with creating new habits needed for long term success.  

 


 

Post-Op Reminders

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Other Documents

All faxes to our office must be accompanied by a fax cover sheet.  Faxes without coversheets are destroyed.  PLEASE PRINT. 

Follow-Up and Non-Bariatric Questionnaire

If you have scheduled a follow-up and have not seen us within the prior 12 months, please complete this questionnaire and bring completed to your consultation.  You may also fax to 443-490-5060 or email to us using our contact form on this website NO LESS than 48 business hours prior to your appointment.

 

Non-Bariatric New Patients, please complete this questionnaire and bring completed to your consultation.  You may also fax to 443-490-5060 or email to us using our contact form on this website NO LESS than 48 business hours prior to your appointment.   

 

If you are unable to complete the document prior to your consultation you may be required to reschedule your appointment.  There is a $5.00 fee for printing this document for you.   

$5.00, if you are unable to print yourself

Follow-Up and Non-Bariatric Patient Forms

This packet includes documents such as our financial policy, HIPAA , agreement regarding our materials, etc. Please bring signed forms to your consultation.  You may also fax them to 443-490-5060 or email using our contact form on this website NO LESS than 48 business hours prior to your consultation.  

GIBNC Services

Services offered by GIBNC. 

Meet our Dietitians

Directions to our Offices and Inclement Weather Policy

Yearly Lab Recommendations

These are the labs that we recommend for a full vitamin panel to detect any vitamin/mineral deficiencies.  As we are not medical doctors but registered dietitians, you must take this slip to your MD to have them write the order up to take to your laboratory.  

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