Patient intake form Question Title * 1. Dr. Hargroder, his staff, and well over one thousand post-operative MGB patients, welcome you to our Mini Gastric Bypass Family! We congratulate you on your decision to Win the Weight Loss Battle for Life and look forward to hearing your “MGB Success Story.” As you begin this journey, we want to make sure we communicate clearly about our deposit policy. Please familiarize yourself with the following information.The placing of your MGB deposit activates the services of Dr. Hargroder’s staff to assist you in preparing for your weight loss journey. The deposit demonstrates your desire to have your procedure on a very specific date, allows our office to initiate steps with the hospital, and removes that particular date/time from being available to any other patient. Once this process has been initiated it is very difficult, and sometimes even impossible to make changes to the date. Even when a date change is possible, it is very costly. Following the deposit guidelines will help insure you do not incur any additional expenses or forfeit your deposit. It is our pleasure to be of service to you.Deposit Policy:• MGB procedure must be scheduled for a specific date. • Deposit is non-refundable when the patient is within 90 days of their surgery date. • MGB Pre-Op is not permitted to postpone/change original MGB date without substantial reasons. Postponement or changing of original MGB date must be made a minimum of 21 days prior to original MGB date. • Deposit will be refunded if MGB date is cancelled due to emergency circumstances or if our office does not approve you for surgery. • Refund requests must be made in writing to be approved and if/when approved will be issued within 30 days of approval. Dr. Hargroder and his staff look forward to working with you in preparing for your amazing weight loss journey. If we can be of any assistance to you, do not hesitate to contact our office. I have read and agree to abide by the deposit policy Comments Question Title * 2. Please provide the following basic demographic information. Name: * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Country: Email Address: * Phone Number: * Question Title * 3. Please provide the name, address, and phone number of your Primary Care Physician (the one who will be providing our office with your History and Physical and lab work). Question Title * 4. What is your date of birth? Date of Birth Date Question Title * 5. Please select your race from the following choices: White Black or African-American Mexican or Hispanic American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander Other (please specify) Question Title * 6. What is your current occupation? Next