Patient Information To continue your application, please fill in the information below. Please note there is a Save and Continue option at the bottom of the page. (Required) First Last Phone(Required)Social Security #(Required)Height (feet)Please enter a number less than or equal to 8.Height (inches)Please enter a number less than or equal to 11.This field is hidden when viewing the formHeight (in inches)(Required)Weight (in pounds)(Required)BMIAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Date of Birth(Required)MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Please enter a number from 15 to 100.Gender(Required) Male Female Marital StatusEmployerPositionPrimary Care DoctorPhone Please tell us how you found usCheck all that apply Internet site/search Family member Friend Physician referral Newspaper Billboard Other Physician NameHow you found usInsurance InformationPlease include a copy of your insurance card (front and back) to avoid a delay in processingPrimary Insurance NameSecondary Insurance NamePrimary ID NumberSecondary ID NumberPrimary Group NumberSecondary Group NumberCustomer Service/Provider Phone NumberCustomer Service/Provider Phone NumberPrimary Subscriber NameSecondary Subscriber NameSubscriber DOBMMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber DOBMMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber SS#Subscriber SS# Physicians Caring for You(Required)NameSpecialtyPhone number Add RemovePlease click the "plus " sign to add more physicians Weight and Diet HistoryMy obesity started:In childhoodAt pubertyAs an adultAfter pregnancyAfter a traumatic eventOther General Questions I snack between meals I eat large meals at one sitting (gorge) I eat a lot of sweets I drink regular soft drinks or "sweet" tea I have forced myself to vomit after eating (binge and purge) I am currently forcing myself to to vomit after eating How often? Please list prior attempts at weight loss(Required)Program or ModalityDatesLength of TimeWeight Loss Add RemoveBe specific for insurance approval (Weight Watchers, Diet, Medications, etc). Please click the "plus " sign to add more rows I have been part of a MEDICALLY SUPERVISED DIET PROGRAM(Required) Yes No Medically superverised diet programs(Required)DatesClinic / Physician Add RemovePlease click the "plus " sign to add more dates Medical HistoryHeart Disease Angina Heart attack CABG (coronary bypass) Angioplasty High cholesterol High blood pressure Number of years?(Required) Diabetes Number of years?(Required)Controlled with Diet Insulin Medication Asthma Sleep apnea Number of years?Date of last sleep study Snoring CPAP Daytime drowsiness Heartburn (GERD) Number of years?Medications Endoscopy Date of last scope Lower back pain Joint pain Thyroid disease Missing teeth How many? Dentures Partials I use a wheelchair or scooter all or most of the time Smoking History(Required) I currently smoke I have quit smoking I have not smoked Years as smoker(Required)Packs per day(Required)How long since you quit?(Required) I use "recreational" drugs TypeDate last usedI drink alcohol Never Rarely Regularly Previous Surgeries(Required)ProcedureDateComplication(s) Add RemovePlease click the "plus " sign to add more procedures Current Medications(Required)Drug nameDoseFrequency Add RemovePlease click the "plus " sign to add more medications Allergies I am allergic to latex List all allergiesInclude medications, foods, environmental, etc. Family HistoryMother Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Father Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Sibling Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Additional InformationPlease supply any additional information for any cancer or heart attack in your familyType your name below(Required)My signature confirms that I have viewed/attended the Lap-Band seminar in its entirety. I understand the risks and benefits of the procedure and understand that if I have any questions regarding the Program, I can contact the Bariatric Office at (502) 361-6059 Δ (Required) First Last Phone(Required)Social Security #(Required)Height (feet)Please enter a number less than or equal to 8.Height (inches)Please enter a number less than or equal to 11.This field is hidden when viewing the formHeight (in inches)(Required)Weight (in pounds)(Required)BMIAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Date of Birth(Required)MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Please enter a number from 15 to 100.Gender(Required) Male Female Marital StatusEmployerPositionPrimary Care DoctorPhone Please tell us how you found usCheck all that apply Internet site/search Family member Friend Physician referral Newspaper Billboard Other Physician NameHow you found usInsurance InformationPlease include a copy of your insurance card (front and back) to avoid a delay in processingPrimary Insurance NameSecondary Insurance NamePrimary ID NumberSecondary ID NumberPrimary Group NumberSecondary Group NumberCustomer Service/Provider Phone NumberCustomer Service/Provider Phone NumberPrimary Subscriber NameSecondary Subscriber NameSubscriber DOBMMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber DOBMMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber SS#Subscriber SS# Physicians Caring for You(Required)NameSpecialtyPhone number Add RemovePlease click the "plus " sign to add more physicians Weight and Diet HistoryMy obesity started:In childhoodAt pubertyAs an adultAfter pregnancyAfter a traumatic eventOther General Questions I snack between meals I eat large meals at one sitting (gorge) I eat a lot of sweets I drink regular soft drinks or "sweet" tea I have forced myself to vomit after eating (binge and purge) I am currently forcing myself to to vomit after eating How often? Please list prior attempts at weight loss(Required)Program or ModalityDatesLength of TimeWeight Loss Add RemoveBe specific for insurance approval (Weight Watchers, Diet, Medications, etc). Please click the "plus " sign to add more rows I have been part of a MEDICALLY SUPERVISED DIET PROGRAM(Required) Yes No Medically superverised diet programs(Required)DatesClinic / Physician Add RemovePlease click the "plus " sign to add more dates Medical HistoryHeart Disease Angina Heart attack CABG (coronary bypass) Angioplasty High cholesterol High blood pressure Number of years?(Required) Diabetes Number of years?(Required)Controlled with Diet Insulin Medication Asthma Sleep apnea Number of years?Date of last sleep study Snoring CPAP Daytime drowsiness Heartburn (GERD) Number of years?Medications Endoscopy Date of last scope Lower back pain Joint pain Thyroid disease Missing teeth How many? Dentures Partials I use a wheelchair or scooter all or most of the time Smoking History(Required) I currently smoke I have quit smoking I have not smoked Years as smoker(Required)Packs per day(Required)How long since you quit?(Required) I use "recreational" drugs TypeDate last usedI drink alcohol Never Rarely Regularly Previous Surgeries(Required)ProcedureDateComplication(s) Add RemovePlease click the "plus " sign to add more procedures Current Medications(Required)Drug nameDoseFrequency Add RemovePlease click the "plus " sign to add more medications Allergies I am allergic to latex List all allergiesInclude medications, foods, environmental, etc. Family HistoryMother Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Father Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Sibling Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Additional InformationPlease supply any additional information for any cancer or heart attack in your familyType your name below(Required)My signature confirms that I have viewed/attended the Lap-Band seminar in its entirety. I understand the risks and benefits of the procedure and understand that if I have any questions regarding the Program, I can contact the Bariatric Office at (502) 361-6059 Δ (Required) First Last Phone(Required)Social Security #(Required)Height (feet)Please enter a number less than or equal to 8.Height (inches)Please enter a number less than or equal to 11.This field is hidden when viewing the formHeight (in inches)(Required)Weight (in pounds)(Required)BMIAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Date of Birth(Required)MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Please enter a number from 15 to 100.Gender(Required) Male Female Marital StatusEmployerPositionPrimary Care DoctorPhone Please tell us how you found usCheck all that apply Internet site/search Family member Friend Physician referral Newspaper Billboard Other Physician NameHow you found usInsurance InformationPlease include a copy of your insurance card (front and back) to avoid a delay in processingPrimary Insurance NameSecondary Insurance NamePrimary ID NumberSecondary ID NumberPrimary Group NumberSecondary Group NumberCustomer Service/Provider Phone NumberCustomer Service/Provider Phone NumberPrimary Subscriber NameSecondary Subscriber NameSubscriber DOBMMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber DOBMMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber SS#Subscriber SS# Physicians Caring for You(Required)NameSpecialtyPhone number Add RemovePlease click the "plus " sign to add more physicians Weight and Diet HistoryMy obesity started:In childhoodAt pubertyAs an adultAfter pregnancyAfter a traumatic eventOther General Questions I snack between meals I eat large meals at one sitting (gorge) I eat a lot of sweets I drink regular soft drinks or "sweet" tea I have forced myself to vomit after eating (binge and purge) I am currently forcing myself to to vomit after eating How often? Please list prior attempts at weight loss(Required)Program or ModalityDatesLength of TimeWeight Loss Add RemoveBe specific for insurance approval (Weight Watchers, Diet, Medications, etc). Please click the "plus " sign to add more rows I have been part of a MEDICALLY SUPERVISED DIET PROGRAM(Required) Yes No Medically superverised diet programs(Required)DatesClinic / Physician Add RemovePlease click the "plus " sign to add more dates Medical HistoryHeart Disease Angina Heart attack CABG (coronary bypass) Angioplasty High cholesterol High blood pressure Number of years?(Required) Diabetes Number of years?(Required)Controlled with Diet Insulin Medication Asthma Sleep apnea Number of years?Date of last sleep study Snoring CPAP Daytime drowsiness Heartburn (GERD) Number of years?Medications Endoscopy Date of last scope Lower back pain Joint pain Thyroid disease Missing teeth How many? Dentures Partials I use a wheelchair or scooter all or most of the time Smoking History(Required) I currently smoke I have quit smoking I have not smoked Years as smoker(Required)Packs per day(Required)How long since you quit?(Required) I use "recreational" drugs TypeDate last usedI drink alcohol Never Rarely Regularly Previous Surgeries(Required)ProcedureDateComplication(s) Add RemovePlease click the "plus " sign to add more procedures Current Medications(Required)Drug nameDoseFrequency Add RemovePlease click the "plus " sign to add more medications Allergies I am allergic to latex List all allergiesInclude medications, foods, environmental, etc. Family HistoryMother Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Father Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Sibling Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Additional InformationPlease supply any additional information for any cancer or heart attack in your familyType your name below(Required)My signature confirms that I have viewed/attended the Lap-Band seminar in its entirety. I understand the risks and benefits of the procedure and understand that if I have any questions regarding the Program, I can contact the Bariatric Office at (502) 361-6059 Δ
