Exit this survey Post Video Acknowledgement Question Title * 1. Contact 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: * Email Address: * Phone Number: * Question Title * 2. Patient's date of birth: Date of birth: Date Question Title * 3. Parent's or legal guardian's full name (If patient is under 18 years of age): Question Title * 4. Program of interest: Medical Weight Loss Adult Bariatric Surgery Adolescent/Teen Bariatric Surgery Adolescent/Teen Wellness180 Program (non surgical weight management) Question Title * 5. Procedure of interest: (please check all that apply) Sleeve Gastrectomy Gastric Bypass Orbera Balloon Adjustable Gastric Banding (Lap Band) Other Other (please specify) Question Title * 6. Have you had weight loss surgery in the past? No Yes (please fax over a referral from your primary care physician to 678-312-6088. We need this PRIOR to your appointment) If you responded "yes" or are looking to establish follow up care, please use the space below to indicate the type of weight loss surgery you had as well as the date. Also, please list the name of the surgeon and the location where the procedure took place. Question Title * 7. Patient's height: Question Title * 8. Patient's weight: Question Title * 9. Please provide the following insurance information: Name of insurance company Name of insured Employer name for insured Date of Birth for Insured Policy/ID number Group number Insurance company phone number Question Title * 10. If you have a secondary insurance carrier, please provide us with the information below. Name of insurance company Name of insured Employer name for insured Date of Birth for Insured Policy/ID number Group number Insurance company phone number Question Title * 11. Bariatric surgeon of preference is: Miguel del Mazo, MD, FACS,MS Robert Richard, MD, FACS Brendon Curtis, MD, FACS Nathaniel Lytle, MD, FACS Question Title * 12. By selecting YES, I certify that I have watched the entire online seminar video provided by The Center for Weight Management. Yes No Question Title * 13. By selecting YES, I authorize Northside Hospital Duluth Center for Weight Management to verify my insurance benefits. Yes No Question Title * 14. By selecting YES, I understand that the next step in this process is to receive an email or phone call from the Center for Weight Management to help you get started in one of our programs and address any questions you may have. Yes No Question Title * 15. I heard about this program through: Internet Friend/Family Physician Print Ad (newspaper/magazine) Billboard Radio Bariatric Surgery Source If physician, please provide name: Question Title * 16. Please list any additional information you may want us to be aware of: Done
