Survey

Our seminars are open to the public.

Have you been interested in learning more about surgical weight-loss options, including minimally invasive procedures? Then consider joining us at a weight loss surgery information session. These seminars are your opportunity to have your questions answered by Weight Loss Surgery Specialists and learn about gastric bypass, Lap-Band and other types of medically-supervised weight loss procedures.

You are not alone on this journey, and we encourage you to bring family and friends along. We cannot wait to meet you. See you there!

PATIENT INFORMATION:

PATIENT INFORMATION: Patient Name:
D O B & Age:
Address:
City/Town:
State:
ZIP:
Marital Status:
Email
Phone Number:

What is your current

What is your current Height?
Weight?

Pick a seminar location to attend in your area.
You may pick more than one location.

Having seminars in your home area is a system that has been setup to make it easier for you to attend our seminars.

Pick a seminar location to attend in your area. You may pick more than one location. Having seminars in your home area is a system that has been setup to make it easier for you to attend our seminars. Pasadena Woodland Texas City The Heights (Houston) Galleria Area (Houston)	Sugar Land Kingwood Katy Pearland Corpus Christi	Lake Jackson Huntsville Dallas Austin
Looking additional seminar locations, please name.

For your convenience we have seminars session during the week and weekends.

What day of the week best fits you?
You may pick more than one.

For your convenience we have seminars session during the week and weekends. What day of the week best fits you? You may pick more than one. Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

For your convenience we have seminars session that start promptly at 1:30 pm or 6:00 pm.

What is the best time for you?

For your convenience we have seminars session that start promptly at 1:30 pm or 6:00 pm. What is the best time for you? 1:30 p.m.

6:00 p.m.

Would you like for Weight Loss Surgery Specialists to pre verify your health insurance for your bariatric benefits?

Would you like for Weight Loss Surgery Specialists to pre verify your health insurance for your bariatric benefits? Yes (if yes, please fill the information about your insurance below)

No

Your Health Insurance Information

The information provided in this form is vitally important in the planning of your care.

While every health insurance policy is unique, it is important to understand your coverage. Read your insurance policy in detail, including what it covers and what it excludes. If your insurance company denies your request, you may be able to appeal the decision.

Your Health Insurance Information The information provided in this form is vitally important in the planning of your care. While every health insurance policy is unique, it is important to understand your coverage. Read your insurance policy in detail, including what it covers and what it excludes. If your insurance company denies your request, you may be able to appeal the decision. Health Insurance Company Name:
Address:
Phone Number:
Policy Number:
Group Number:
Renewal Date:

Insurance Policy Holder (if other than patient)

Insurance Policy Holder (if other than patient) Name:
D O B:
Social Security:
Relationship:
Address if different:
Employer:

Pre-Verify my insurance for

Pre-Verify my insurance for Weight Loss Surgery	Weight Loss Management	Both
Other (please specify)

If Yes for weight loss surgery, what type are you interested in?

If Yes for weight loss surgery, what type are you interested in? Gastric Bypass Surgery (RNY)

Lap-Band

Gastric Sleeve

Revision - Had weight loss surgery before

PATIENT PRIMARY CARE PHYSICIAN NAME:

PATIENT PRIMARY CARE PHYSICIAN NAME: Physician Name:
Address:
City/Town:
State:
ZIP:
Phone Number:

ARE YOU RECEIVING DISABILITY BENEFITS?

ARE YOU RECEIVING DISABILITY BENEFITS? Yes	No
If you answered YES to receiving disability benefits, REASON FOR DISABILITY?

Medicare / Medicaid?

	Yes	No
Do you have Medicare?	*Medicare / Medicaid? Do you have Medicare? Yes	Do you have Medicare? No
Do you have Medicaid?	Do you have Medicaid? Yes	Do you have Medicaid? No

Diagnosed or Treated

	Yes	No
Have you been diagnosed or treated for high blood pressure?	*Diagnosed or Treated Have you been diagnosed or treated for high blood pressure? Yes	Have you been diagnosed or treated for high blood pressure? No
Have you been diagnosed or treated for diabetes?	Have you been diagnosed or treated for diabetes? Yes	Have you been diagnosed or treated for diabetes? No
Do you have high blood cholesterol?	Do you have high blood cholesterol? Yes	Do you have high blood cholesterol? No
Do you have high blood fats or triglycerides?	Do you have high blood fats or triglycerides? Yes	Do you have high blood fats or triglycerides? No
Have you ever been diagnosed with asthma?	Have you ever been diagnosed with asthma? Yes	Have you ever been diagnosed with asthma? No
Have you been diagnosed or treated for heartburn or gastro-esophageal reflux (GERD)?	Have you been diagnosed or treated for heartburn or gastro-esophageal reflux (GERD)? Yes	Have you been diagnosed or treated for heartburn or gastro-esophageal reflux (GERD)? No
Have you ever had stomach ulcers?	Have you ever had stomach ulcers? Yes	Have you ever had stomach ulcers? No
Have you ever had blood clots in your leg veins?	Have you ever had blood clots in your leg veins? Yes	Have you ever had blood clots in your leg veins? No
Have you ever been anemic?	Have you ever been anemic? Yes	Have you ever been anemic? No
Have you ever had iron deficiency or taken iron?	Have you ever had iron deficiency or taken iron? Yes	Have you ever had iron deficiency or taken iron? No
Have you ever been diagnosed with hypothyroidism?	Have you ever been diagnosed with hypothyroidism? Yes	Have you ever been diagnosed with hypothyroidism? No
Have you ever had thyroid surgery?	Have you ever had thyroid surgery? Yes	Have you ever had thyroid surgery? No
Do you take thyroid replacement medication?	Do you take thyroid replacement medication? Yes	Do you take thyroid replacement medication? No

Do you suffer from a sleeping disorder?

Do you suffer from a sleeping disorder? Yes

No

How did you hear about Weight Loss Specialists / Give Obesity the Boot?

For your convenience the Health History Form can be filled out online in the comfort of your own home.

Copy here
http://wlsshelp.com/HealthHistoryForm/tabid/170/Default.aspx
to fill out your Health History Form

Filling out your history form online allows us to start the process of your case.
By reviewing your health history
Preparing your chart for the seminar

DIGITAL SIGNATURE: I have provided complete and accurate information to the best of my knowledge. Typing my name and today's date in the box below will serve as my digital signature. (NOTE: If you are under 18, please have a parent or guardian sign as well).
Your digital signature allows us to start processing your case.

You will also Hand Signed & Dated in person at the time of your first appointment / seminar.

DIGITAL SIGNATURE: I have provided complete and accurate information to the best of my knowledge. Typing my name and today's date in the box below will serve as my digital signature. (NOTE: If you are under 18, please have a parent or guardian sign as well). Your digital signature allows us to start processing your case. You will also Hand Signed & Dated in person at the time of your first appointment / seminar. Patient Signature - Date

Parent Guardian - Date

Join us for a Weight Loss Surgery Seminar