Bariatric Surgery Screening Form

Step 2: Complete the Screening Questions
First Name*
Last Name*
Date of Birth*
Email*
Phone Number*
Height*
Weight*
Where would you like to go for your surgery appointments?*
What are the two types of bariatric surgery we perform?*
Who is your first appointment with?*
Who are the key players on the bariatric team?*
True or False: Weight loss surgery is considered elective*
Are you required to quit smoking?*
The Baritastic App will help you through this journey. Which of the following does the app NOT do?*

Track foodSet remindersTrack stepsProvide access to recipes and support groupsSchedule appointments
True or False: Weight loss surgery risks include nausea, vomiting, and dehydration.*
True or False: You will need to take supplements for the rest of your life after surgery.*
True or False: After weight loss surgery you are more likely to become pregnant unexpectedly.*
Which bariatric surgery video did you watch?*
Type your first and last name as agreement that you have watched this video in full.*
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Step 2: Complete the Screening Questions