New Patient Form

Please fill in the information below prior to your appointment

Patient Information

First Name

Last Name

Date of Birth

Social Security Number

This information is encrypted

Patient Contact Information

Phone Number

Email Address

Mailing Address

City

State

Zip Code

Please upload an image of the front of your Driver License

Add file

Please upload a file

Please upload an image of the back of your Driver License

Add file

Please upload a file

Patient Emergency Contact Information

First Name

Last Name

Phone Number

Relationship

In case of an emergency, do we have permission to contact and share information with this person?

Yes No

Primary Care Physician

First Name

Last Name

Phone Number

Adress

City

State

Zip Code

If you have any previous labs, EKG, imaging, and/or biopsy results of any kind, please upload them here:

Add file

Please upload a file

Insurance Information

Method of Payment

Insurance Self-pay

If you chose "Insurance" please fill out the information below. If you chose "Self-pay" please insert N/A in the information below.

Name of Insurance policy holder

Policy/plan number

Please upload an Image of the front of your primary insurance card

Add file

Please upload a file

Please upload an image of the back of your primary insurance card

Add file

Please upload a file

If applicable, secondary Insurance

Secondary Insurance Policy/Plan number

Please upload the front of your secondary insurance card.

Add file

Please upload a file

Please upload the back of your secondary insurance card.

Add file

Please upload a file

Reason for Visit:

Please select from the options below

General Surgery Consulation Bariatric Surgery Consultaiton Weight Loss Consultation Other

If other, please specify reason below.

Medical History:

Do you have a CPAP?

Yes No

Is there anything else regarding your medical history that we should be aware of?

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Do you have any allergies?

Pharmacy name

Pharmacy Phone Number

Surgical History

Have you had surgery in the past?

Yes No

If yes, please specify procedure and date (best estimate) of surgery.

Personal History

Do you smoke?

Regularly Occasionally/Socially No

If yes, what type (i.e. cigarettes, vaping, marijuana, etc)?

Do you drink alcohol?

Regularly Occasionally/Socially No

Do you have a healthy and balanced diet?

Regularly Occasionally/Socially No

Review of Systems

Diet History

What diet have you previously tried?

(List diet name with duration (days/weeks/months) and how much weight you lost and regained if any)

Your information will be encrypted.