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⮜ Return to Weight Management

Weight Management Form

Type of Service(Required)

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Gender(Required)

Date of Birth

MM slash DD slash YYYY

Current Height(Required)

Current Weight(Required)

Check Any health conditions you have:

Diabetes

High Blood Pressure

High Cholesterol

Heart Disease

Sleep Apnea

GERD/acid reflux

Fatty Liver

Mental Health Disorder

Are you interested in medical weight management or bariatric surgery options

Medical weight management with medications

Medical weight management without medication

Bariatric Surgery

Tobacco use status

Never used

Currently use

Quit

When did you stop smoking?

Do you see a mental health provider?

Yes

No

Name of mental health provider?(Required)

Prior Bariatrics

New patient, never had bariatric surgery

Revision, history of bariatric surgery

What type and when?

How did you hear about our program?

Primary Insurance Subscribers Employer(Required)

Second Insurance Subscribers Employer (optional)

Policy #

Group #

Team Member Portal Refer A Patient Giving

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Topeka Campus
1500 SW 10th Ave.
Topeka, KS 66604
(785) 354-6000
Para Español: (833) 692-3054

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