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Obesity Institute
About the Obesity Institute
Prevention and Wellness Programs
Weight-Loss Treatment
IDEAL Clinic
Weight-Loss Surgery
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Consultation Request

This form is for families who are interested in learning more about our weight-loss surgery program for adolescents. The purpose of this form is to give our staff some information to move forward with you and your child in your journey to better health. Parents or guardians must complete this form and the child should be 12 years or older.

Please expect a response from one of our staff members in 3 business days.

Intake Information
Relationship to patient
Please specify your relationship to patient:*
Patient Name
Patient DOB
Parent / Caregiver
Address
Phone
Email Address*
Reason for contact
Information request
e-Consult
Set up office visit
Second opinion
How did you find us?
Internet
Word of mouth (friend)
Physician Referred
Other
Health self-assessment
Height
Weight
Age
Is Your Child Currently At His/Her Highest Weight?
Years overweight
Does your child have any of the following conditions?
Diabetes
Snoring
Hiatal Hernia
Thyroid Problems
Hypertension
GastroesophagealReflux
Do you have a family history of any of the following conditions?
Obesity
Diabetes
Sleep Apnea
Thyroid Problems
Hypertension
GastroesophagealReflux
 
 


 
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