Get the free Bariatric Referral Form - Kallus

Indications for Bariatric Surgery ? ? ? Bariatric and Metabolic Weight Loss Center BMI ? 40 BMI ? 35 + 1-2 co-morbidities BMI ?30 + 1-2 co-morbidities (gastric band) Department of Surgery (631) 444-7413

How to fill out bariatric referral form

How to Fill Out Bariatric Referral Form:

1. Start by obtaining the bariatric referral form from your healthcare provider or bariatric center. This form is typically required for individuals who are seeking bariatric surgery or treatment.
2. Fill in your personal information accurately. This typically includes your full name, address, contact number, date of birth, and insurance information. Make sure to double-check the accuracy of your details to avoid any delays or errors in processing.
3. Provide your medical history. This section requires you to disclose any past or current medical conditions, surgeries, medications, or allergies that may be relevant to your bariatric treatment. It is crucial to be honest and thorough in providing this information.
4. Include a detailed description of your weight loss journey. This may include your weight history, previous weight loss attempts, diets you have tried, exercise routines, and any relevant lifestyle changes you have made. The healthcare provider needs this information to assess your suitability for bariatric surgery and tailor the treatment plan accordingly.
5. Your healthcare provider may request specific lab tests or diagnostic imaging. Attach copies of the requested reports, such as blood work results, X-rays, or any other relevant investigations. These records help the healthcare provider evaluate your current health status and identify potential risks or complications.
6. Answer any additional questions or sections on the form thoroughly. Some referral forms may include sections that require you to provide details about your mental health, social support system, motivation for pursuing bariatric treatment, or any specific concerns you may have. Take your time to answer these questions thoughtfully and honestly.

Who Needs Bariatric Referral Form:

1. Individuals who are interested in pursuing bariatric surgery or treatment may need to fill out a bariatric referral form. This form is typically required by healthcare providers or bariatric centers as part of their screening process.
2. Patients who meet certain criteria for bariatric surgery, such as having a high body mass index (BMI) or medical conditions related to obesity, may be directed to fill out a referral form. This form helps healthcare providers gather essential information to evaluate the patient's eligibility for bariatric treatment.
3. Healthcare professionals may also use the bariatric referral form to assess the patient's overall health status, including their readiness for the surgery, any potential risks or complications, and the patient's commitment to long-term lifestyle changes.

In summary, filling out a bariatric referral form requires providing accurate personal information, disclosing medical history, describing weight loss journey, attaching requested reports, and answering additional questions. This form is typically needed by individuals interested in pursuing bariatric surgery or treatment, helping healthcare providers assess eligibility and develop personalized treatment plans.

For pdfFiller’s FAQs

What is bariatric referral form?

Bariatric referral form is a document used to refer patients to a bariatric surgery program for evaluation and potential treatment.

Who is required to file bariatric referral form?

Healthcare providers, such as doctors or medical professionals, are required to file the bariatric referral form.

How to fill out bariatric referral form?

The bariatric referral form should be completed with the patient's information, medical history, and reason for referral to the bariatric surgery program.

What is the purpose of bariatric referral form?

The purpose of the bariatric referral form is to initiate the process of evaluating and potentially treating patients with severe obesity through bariatric surgery programs.

What information must be reported on bariatric referral form?

The bariatric referral form must include the patient's name, contact information, medical history, current weight and height, and reason for referral.

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