DFW Bariatric Institute - Medical Packet (email To Info .

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DFW Bariatric Institute - Medical Packet(email to info@DFWBI.com or fax to 817-581-6127)PATIENT INFORMATIONLast name:First:Maiden Name:SSN:Ethnicity:D.O.B:Home Phone #:Cell Phone #:Where should we call? Home Cell WorkCan we email? Yes NoOccupation:Email:City:State:Employer:Family Physician:Sex:M FWork Phone #:May we leave message? Yes NoStreet address:Age:ZIP:Type:full time part timeReferring Physician:Best time to reach you? Time:Cardiologist:Psychologist:Day of the week:Pharmacy:Telephone Number:INSURANCE INFORMATIONPrimary Ins.:ID#:Ins. Phone #:Ins. Address:Policy Holder Name & DOB:– WE WILL NEED A PHOTO OR COPY OF YOUR INSURANCE CARD EMAILED TOINFO@DFWBI.COMGroup#:Employer:Employer address:Employer phone #:(Secondary Ins.:Ins. Phone #:ID#:)Group#:Ins. Address:Policy Holder Name & DOB:Employer:Employer address:Employer phone #:()IN CASE OF EMERGENCYName:Relationship:Home phone #:()Work phone #:()Assignment of Insurance Benefits and/or Release of Medical Information: is authorized to my insurance company. The undersigned herebyauthorizes DFW Bariatric Institute, RCPS, Inc, and Westwing Physicians to furnish all information to said companies and/or payers identified abovethat may be necessary for the completion of my medical claims. Payment of insurance claims are hereby assigned to these companies for applicationon the patient's bill. The undersigned and/or patient will be responsible for charges not covered by this assignment and/or not paid by said payers.Release of information, assignment of insurance benefits and the right to appeal, and direct payment are also authorized to the listed providers whorender care to myself or my dependents."1

Signature of Patient or Parent if MinorDateI attest that this information is true, accurate and complete to the best of my knowledge"2

Authorization for Use and Disclosure of Protected Health Information (PHI)DFW Bariatric InstitutePhone 817-581-6100 Fax 817-581-6127Last name:First:Telephone #:Date of Birth:Street address: City:I authorizeSSN#:State: ZIP Code:(Patient’s physician ) or Facilityto disclose my medical record information and / or protected health information for the purpose of BariatricSurgery to:DFW Bariatric Institute5204 Colleyville BlvdColleyville, Texas 76034Phone 817-581-6100 Fax 817-581-6127I authorize DFW Bariatric Institute and associates to disclose my medical record information and / orprotected health information to:(Identify your insurance Company):Type of access requested:1. Letter of Medical Necessity and medical clearance for surgery2. Progress Notes:3. Lab Work4. Weight history (one progress note per year x5 years of documented weight)5. Medication Record6. Operative Report7. Band Flow Sheet8. Other:I acknowledge, and hereby consent to such, that the released information may containalcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information.(Initials)I understand that this authorization may be revoked by me at any time except to the extent that action has been takenin reliance upon it.The information used or disclosed pursuant to the authorization maybe subject to re-disclosure by the recipient and nolonger protected. I understand that the condition for release is not based on payment for treatment and care,enrollment or eligibility or whether I sign the authorization.Fees/charges will comply with all laws and regulations applicable to release of information.I have read the above and authorize the disclosure of the protected health information as stated.Signature of Patient or Parent if MinorDateI attest that this information is true, accurate and complete to the best of my knowledge"3

PATIENT HISTORY QUESTIONNAIRELast name:First:Birth date:Age:Height:Weight:BMI:Reason for seeing the doctor? Do you know whichsurgery you are interested in?Please list all prior surgeries:I agree to a blood transfusion in anemergency situationDo you currently have an abdominal / incisional hernia?Yes NoDo you take any blood thinning medications such asCoumadin, warfarin, aspirin, or Plavix? Yes NoTape Allergies?Yes NoLatex Allergies?Yes NoDo take any NSAIDS such as Ibuprofen, Motrin, Aleve,Celebrex or Naprosyn?Yes NoI use tobacco(including smoke, dip, chew, nicotine gum/patches): How Often:Did You Quit:I drink alcohol: How Often:How Many Years:I use recreational Drugs: How Often:How Many Years:WhenWhen Did You Quit:How Many Years:When Did You Quit:I use Birth Control: Pills Condoms Tubal Ligation Other:Do you have or use any of the following:HYPERTENSION (HIGH BLOOD PRESSURE)DIABETES MELLITUSSLEEP APNEA - CPAP or BI PAPHEART DISEASELUNG DISEASE (COPD/Emphysema) - Home OxygenPULMONARY EMBOLISMSHORTNESS OF BREATH AND EXERCISE INTOLERANCE DUE TOOBESITYASTHMABLOOD CLOTSBLOOD TRANSFUSIONLIVER DISEASE ( Hepatitis B, Hepatitis C )HIV/ AIDSKIDNEY DISEASE - DialysisTHYROID PROBLEMSLUPUSOTHER:HEARTBURN/REFLUXINDIGESTION / DYSPEPSIAPROBLEMS SWALLOWING / EXCESSIVE CLEARING OF THROATACID METALLIC TASTE IN MOUTH / SOUR STOMACHCOUGHING / HOARSENESSVOMITING OR REGURGITATION WHEN LYING DOWNFOOD GETS STUCK IN YOUR THROATGASSINESS / BLOATINGSTOMACH ULCERCOLITISCROHN’S DISEASE/ ULCERATIVE COLITISHYPERCHOLESTEROLEMIA (ELEVATED CHOLESTEROL)HYPERTRIGLYCERIDEMIA (ELEVATED TRIGLYCERIDES)URINARY STRESS INCONTINENCE (WEAK BLADDER)CHRONIC BACK AND JOINT PAINARTHRITISMIGRAINE HEADACHESEDEMA (LEG SWELLING)DEPRESSION / BIPOLAR DISORDER/ANXIETYFREQUENT PREDNISONE USEFAMILY HISTORY: OBESITY, DIABETES, HYPERTENSION, HEARTDISEASE, CANCER"4

Signature of Patient or Parent if MinorDateI attest that this information is true, accurate and complete to the best of my knowledge"5

MEDICATIONS AND PHYSICIANSLast name:First:Medication Allergies?Yes NoD.O.B.:If Yes, please list:Please list ALL medications you are currently taking: this includes over-the-counter products, prescriptionmedications and any herbal supplements/vitamins you ateDatePlease list doctors you are currently seeing (including PCP, heart doctor, psychiatrist, therapist, dietitian,etc); if you do not know the address (including ZIP code), please call them to obtain a complete address.Name:Specialty:Phone:Fax:Mailing Address:"6

Signature of Patient or Parent if MinorI attest that this information is true, accurate and complete to the best of my knowledgeDate"7

WEIGHT RELATED HISTORYLast name:First:D.O.B.:Weight History – Please list your average weight over the last 5 yearsYear:Age:Weight:Year:Age:Weight:Supervised Weight Loss Attempts – Please check all of the weight loss efforts you have triedHome Gym EquipmentGym MembershipHealth SpaCalorie CountingHigh ProteinLow CarbLow FatHypnosisAtkins DietMayo Clinic DietRichard SimonsScarsdale DietSugar BustersSlim FastSouth Beach DietAcupunctureDiet Pills from MDDiet Shots from MDDiet CenterJenny CraigOvereaters AnonymousOptifast / MedifastLA Weight LossNutri SystemPsychological CounselingSupervised CalorieCountingT.O.P.S.Weight WatchersHarris FastMetabolife OTCPhenterminePondiminPhen fen Duration:ReduxTenuateTrimspa OTCXenicalZenadrine OTCCheck Each Medication you have tried:Acutrim OTCAdipexAmphetaminesDexatrim OTCFastinHerbal Remedies OTCIonaminMeridiaLevel of Limitations: Shortness of breath/painAerobics-WaterBikingOrganized ExerciseStairsSwimmingWalkingDo you use any of these walking aids daily?CaneWalkerWheelchairMotorized Cart"8

EMOTIONAL / PSYCHOLOGICAL EVALUATIONLast name:First:D.O.B.:Please use the scale below to describe to what degree the problems listed below have BOTHERED orDISTRESSED you during the past week, including today.0123Not at AllA Little BitModeratelyQuite a BitExtremely4"9

Nervousness or shakiness insideUnwanted thoughts, words, or ideas that won’t leave your mindThe idea that someone else can control your thoughtsFeeling others are to blame for most of your troublesTrouble remembering thingsFeeling easily annoyed or irritatedFeeling afraid in open spaces or in the streetThought of ending your lifeHearing voices that other people do not hearFeeling that most people cannot be trustedCrying easilyFeeling of being trapped or caughtSuddenly scared for no reasonTemper outbursts that you could not controlFeeling afraid to go out of your house aloneFeeling blueWorrying too much about thingsFeeling fearfulOther people being aware of your private thoughtsHaving to avoid certain things, places, or activities because they frighten youYour mind going blankFeeling hopeless about the futureTrouble concentratingHaving thoughts that are not your ownHaving urges to beat, injure, or harm someoneHaving urges to break or smash thingsHaving ideas or beliefs that others do not shareSpells of terror or panicGetting into frequent argumentsFeeling nervous when you are left aloneFeeling so restless you couldn’t sit stillFeelings of worthlessnessFeeling that familiar things are strange or unrealShouting or throwing thingsThoughts of suicideThe idea that you should be punished for your sinsThe idea that something is wrong with your mindFeeling afraid to travel on buses, subways or trains"10

WHAT YOU HOPE TO ACHIEVELast name:First:D.O.B.:In your own words, please describe what you hope to accomplish and how you believe your life will changeby losing weight:"11

Sleep Habit/ Epworth ScaleName: DOB:Height: Weight:Do you have or have you had trouble sleeping?If yes, what symptoms do you experience?Morning Headaches?Snoring?Waking up at night?Insomnia?Daytime Drowsiness?Restless sleep?High blood pressure?Anxiety?Depression? YesYesYesYesYesYesYesYesYes NoNoNoNoNoNoNoNoNo Yes NoLeg Movements during sleep? Yes NoNarcolepsy-Daytime sleep attacks? Yes NoRestless legs just prior to or while falling asleep? Yes NoNumber of Naps a Day:Do you clinch or grind your teeth? Yes NoDo you feel rested when you wake up in the morning? Yes NoHave you ever fallen asleep at the wheel? Yes NoFalling asleep at inappropriate times? Yes NoDo you ever wake up from a deep sleep choking and coughing? Yes NoHas anyone ever told you that you stopped breathingwhile you sleep (an observed apnea)? Yes NoIf Yes, how often does this occur:Have you ever had a sleep study?Did you have sleep apnea?If you have sleep apnea do you use:Please indicate the chance of dozing in each situation using the Yes Yes CPAPscale: No Date: No BiPAP0 no chance of dozing1 slight chance of dozing2 moderate chance ofdozingSituationDozingSitting and readingWatching TelevisionSitting inactive in a public place (e.g. a theater or meeting)As a passenger in a car for an hour without a breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after lunch without alcoholIn a car, while stopped for a few minutesTotal Score:Chances ofOverall, how long have you been experiencing these symptoms? years / months / days"12

Signature of Pa/ent or Parent if MinorDateI attest that this information is true, accurate and complete to the best of my knowledge"13

DFW Bariatric InstituteDear Patient,Please read this, initial each item, and sign below indicating that you understand the guidelines.APPOINTMENT If you find that you are unable to keep your appointment, please call to cancel 24 hours in advance sothat a time will be available for other patients. If you are more than 10 minutes late to your appointment, you may be asked to reschedule. There will be a 25.00 charge if 24 hours notice is not given for cancellations.InitialsINSURANCE AND FEES I agree to pay for any and all medical services I receive from the doctor/providers of this practice thatmy insurance company refuses to pay, for whatever reason. This office will file a claim in my behalf,however, if my insurance company refuses to pay, for whatever reason (e.g., non-covered services, plandoes not pay for preventive medicine visits or my failure to secure a referral from my primary carephysician) I will pay for the visit upon written/verbal notice of their refusal. Failure to pay within 45 daysof filing is, for the purpose of this agreement, a refusal to pay. There is a 20.00 fee per form that must be paid in advance before we complete and/or return the formfor Disability Insurance forms, Leave of Absence forms, and/or Return to work forms.InitialsACCOUNT BALANCES AND RETURNED BANK ITEMS Our office staff will always be glad to discuss fees with you. Should you have financial problems thatresult in the delay of payment, please contact the office manager and discuss the situation. We will notknow you are having problems unless you tell us. We will make every effort to work out an acceptablepayment plan to enable you to take care of your obligation. Patient account balances that exceed 60 days without payment will be turned over to our collectionagency. We accept Cash, Check, Visa, MasterCard, and Care Credit or Money orders. If your check is returned from the bank, we will add the “returned fee” to your account in the amount of 30.00.InitialsCHILD POLICY We consider ourselves a family friendly business and welcome the support that your family can provideto you during your weight loss journey. However out of respect for fellow patients, the safety ofyour children and productivity of our staff we kindly ask that no children under the age of 17 accompanyyou to the back for your appointment. Further, children under the age of 17 may not be left unattendedin the waiting area. Children are not allowed in classes.InitialsI have read, understand, and agree to all of the above statements. I understand the charges not covered bymy insurance, as well as applicable co-payment and deductible are my responsibility.Patient SignatureDate"14

DFW Bariatric InstitutePatient Consent for Use of Email CommunicationsTo better serve our patients, this office has established an email address for some forms of communication.For routine matters that do not require immediate response, please feel free to contact us atappointments@DFWBI.com. Please remember however, that this form of communication is not appropriate foruse in an emergency. The turnaround time for routine patient communications is 24 hours. The serviceprovider may delay message delivery. Should you require urgent or immediate attention, this mediumis not appropriate.When sending emails please put the subject of your message in the subject line, so we can process it moreefficiently. Also make sure to put your name, date of birth and return telephone number in the body of themessage. We also ask that you acknowledge receipt of emails coming from this office by using the auto replyfeature. Communications relating to diagnosis and treatment will be filed in your medical record.This office is dedicated to keeping your medical record information confidential. Despite our best efforts, dueto the nature of email, third parties may have access to messages. When communicating from work, youshould be aware that some companies consider email corporate property and your messages may bemonitored. Even when emailing from home, you may feel that access to your email is not well controlled, soyou should take that into consideration. In addition, you should be aware that, although addressed to me, mystaff and/or colleagues would have access to this information.I understand that this office will not be responsible for information loss or delay or breaches in confidentialitythat are due to technical factors beyond this office’s control. I understand and agree to the above email policy.By signing below, you are agreeing that we may send medical related correspondence to you via email, andthat we may respond to your emails to us via email.Date:Patient signaturePhysician Assistant Consent FormThis facility has on staff a Physician Assistant to assist in the delivery of medical care. A Physician Assistant isnot a doctor. A Physician Assistant is a graduate of a certified training program and is licensed by the stateboard. Under the supervision of a Physician, a Physician Assistant can diagnose, treat, and monitor acute andchronic diseases as well as provide health maintenance care. Supervision does not require the constantphysical presence of the supervising physician, rather the overseeing of activities of and acceptingresponsibility for the medical services provided. A Physician Assistant may provide such medical services thatare within his/her education, training, and experience. These services may include: Obtaining histories and performing physical exams Ordering and/or performing diagnostic and therapeutic procedures Formulating a working diagnosis Developing and implementing a treatment plan Monitoring the effectiveness of therapeutic interventions Offering counseling and education Supplying sample medications and writing prescriptions Making appropriate referralsI have read the above, and hereby consent to the services ofa Physician Assistant for my health care needs. I understand that at any time I can refuse to see the PhysicianAssistant and request to see a Physician.Patient signatureDate:"15

DFW Bariatric Ins/tute Authoriza/onDFW Bariatric Ins.tute loves to share the success stories of our pa.ents with others, to help them make the decision tostart their weight loss journey. We believe interac.on of our pa.ents is one of the most valuable forms of research andwe support and encourage this through mul.ple mediums. Please indicate below in what ways you would like topar.cipate in this process.I (Printed Name) authorize DFW Bariatric Ins.tute to use anddisclose my informa.on to include: Health related issues that resulted in my decision to have bariatric surgeryDetails of my bariatric surgeryInterviews you provide and their transcriptsYour imageIndicate the ways you would like to par.cipate by placing your ini.als below:DFWBI.com & DrDKim.net web siteDFW Bariatric Ins.tute Social Media, consis.ng of, but not limited to Facebook, TwiOer, Instagram, Pinterest,YouTube, LinkedIn and Google Plus.Crea.on and distribu.on of DFW Bariatric Ins.tute Television Commercials, Billboards and Radio spots.Crea.on and distribu.on of Television programs featuring DFW Bariatric Ins.tute.Crea.on and distribu.on of Radio programs featuring DFW Bariatric Ins.tute.Crea.on and distribu.on of Videos to be presented in DFW Bariatric Ins.tute wai.ng rooms.DFW Bariatric Ins.tute will be working with several companies that support their marke.ng ac.vi.es to share your story.These companies consist of, but are not limited to Silvr Social, Rosemont Media, and United Media Group. You have theright to revoke this authoriza.on by providing a wriOen request to DFWBI, 5204 Colleyville Blvd, Colleyville, Texas 76034.In the event that you par.cipate in a produc.on and you sign a talent release, you will be held to the talent releaseagreement which is a separate contract. DFW Bariatric Ins.tute cannot require the pa.ent to sign this authoriza.on inorder to receive treatment. The informa.on disclosed pursuant to the authoriza.on may be redisclosed by recipientsand no longer be protected by the federal privacy regula.ons. This authoriza.on will expire if the below signed decidesto terminate the prac.ce, pa.ent rela.onship with DFWBI.Signature of Pa.ent: Date:Note: If the pa.ent’s personal representa.ve signs the authoriza.on, the authoriza.on also must include a descrip.onof that person’s authority to act for the pa.ent."16

DFW Bariatric InstitutePERSONS WHO ARE AUTHORIZED TO RECEIVE INFORMATION:HEALTH INFORMATION OUR OFFICE COLLECTS OR RECEIVES ABOUT YOU MAY BE DISCLOSED TO THEFOLLOWING PERSONS:NAME: RELATIONSHIP:NAME: RELATIONSHIP:USE AND DISCLOSURE OF INFORMATION:PLEASE INITIALI AUTHORIZE THE PERSON(S) LISTED ABOVE TO RECEIVEALL HEALTH INFORMATION ABOUT APPOINTMENTS, TREATMENT AND/OR OTHERINFORMATION PERTINENT TO MY HEALTHCARE AND /OR PAYMENT FOR MYHEALTHCARE.-- OR –PLEASE INITIALI DO NOT AUTHORIZE ANY INFORMATION TO BEDISCLOSED TO ANY OTHER PARTIES EXCEPT TO ME AS THE PATIENT.YOU MAY REVOKE OR TERMINATE THIS AUTHORIZATION BY SUBMITTING A WRITTEN REVOCATION TO OUR OFFICE TO ATTENTIONOF THE PRIVACY OFFICIAL OR OTHER AUTHORIZED REPRESENTATIVE. HOVEVER, YOUR DECISION TO REVOKE THE AUTHORIZATIONWILL NOT BE IN EFFECT OR UNDO ANY USE OF DISCLOSURE OF INFORMATION THAT OCCURRED BEFORE YOU NOTFIED US OF YOURDECISION.COMMENTS:PLEASE INITIALI have received the information entitled“Notice of Privacy Policies and Practices”PRINT NAMEDOBSIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVEDATE"17

NOTICE OF PRIVACY POLICIES AND PRACTICESForDFW Bariatric InstituteDEAR PATIENT:THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TOTHIS INFORMATION. PLEASE REVIEW IT CAREFULLY.INTRODUCTIONAt our practice, we are committed to treating and using protected health information about you responsibly. ThisNotice describes the personal information we collect and how and when we use or disclose that information. It alsodescribes your rights as they relate to your protected health information. This Notice is effective April 14, 2003 andapplies to all protected health information as defined by federal regulations.UNDERSTANDING YOUR MEDICAL RECORD/HEALTH INFORMATIONEach time you visit our office, a record of your visit is made. Typically, this record contains information about your visitincluding your examination, diagnosis, test results, treatment as well as other pertinent healthcare data. Thisinformation, often referred to as your health or medical record, serves as a:o Basis for planning your care and treatmento Means of communication with other health professionals involved in your careo Legal document outlining and describing the care you receivedo A tool that you, or another payer (your insurance company) will use to verify that services billed were actuallyprovidedo An education tool for medical health providerso Basis for public health officials who might use this information to assess and/or improve state as well asnational healthcare standardso A tool that we can reference to ensure the highest quality of care and patient satisfactionUnderstanding what is in your record and how your health information is used helps you to ensure its accuracy, determine what entitieshave access to your health information, and make an informed decision when authorizing the disclosure of this information to otherindividuals.YOUR RIGHTSYou have certain rights under the federal privacy standards. These include:o The right to request restrictions on the use and disclosure of your protected health information; must be in writingo The right to receive confidential communications concerning your medical condition and treatmento The right to inspect and copy your protected health informationo The right to amend or submit corrections to your protected health informationo The right to receive a printed copy of this noticeOUR RESPONSIBILITIESOur office is required to:o Maintain the privacy of your health informationo We are required by law to provide you with this Notice as to our legal duties and privacy practices with respect to informationwe collect and maintain about youo Abide by the terms of this noticeo Notify you if we are unable to agree to a requested restriction and acknowledge revisions with notificationso Accommodate reasonable requests you may have regarding communication of health information via alternative means and/locationsAs permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies andpractices may be required by changes in federal and state laws and regulations. Any updates will be posted in our office. We will notuse or disclose your health information without your authorization, except as described in this notice."18

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HOW WE MAY USE AND/OR DISCLOSE YOUR HEALTH INFORMATIONPATIENT INFORMED CONSENT, MEDICAL & SURGICAL WEIGHT LOSSWe will use your health information for treatment. Your health information may be used by staff members or disclosed to other healthcare professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example:results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatmentor who may be consulted by staff members.We will use your information for payment. Your health plan may request and receive information on dates of service, the servicesprovided, and the medical condition being treated in order to pay for the service rendered to you.We will use your information for regular health operations. Your health information may be used as necessary to support the day-today activities and management of NHFP. For example: information on the services you received may be used to support budgetingand financial reporting and activities to evaluate and promote quality.Business Associates. In some instances, we have contracted separate entities to provide services to us. These “associates” requireyour health information in order to accomplish the tasks that we ask them to provide. Some examples of these “business associates”might be a collection agency, answering service and computer software/hardware provider.Communication with family. Due to the nature of our field, we will use our best judgment (ex: emergency situations) when disclosinghealth information to a family member, other relatives, or any other person that is involved in your care or that you have authorized toreceive this information. We will ask patients 18 years and older to sign a consent to release information to anyone other thanthemselves.Healthcare Oversight. Federal law requires us to release your information to an appropriate health oversight agency, public healthauthority or attorney, or other federal/state appointee if there are circumstances that require us to do so.Public health reporting. Your health information may be disclosed to public health agencies as required by law.Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to supportgovernment audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.Appointment reminders. This practice may use your information to remind you about upcoming appointments. Typically, appointmentreminders are sent by mail or a brief, non-specific message may be left on your answering machine / voicemail.Other uses and disclosures. Disclosure of your health information or its use for any purpose other than those listed above requiresyour specific written authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure ofinformation that occurred before you notified us of your decision.FOR MORE INFORMATION OR TO REPORT A PROBLEMIf you have complaints, questions or would like additional information regarding this notice or the privacy practices of DFW BariatricInstitute please contact:PRIVACY OFFICE5204 ColleyvilleColleyville, TX 76034817-581-6100If you believe that your privacy rights have been violated, please contact the aforementioned practice Privacy Official, or, you may file acomplaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing acomplaint with either the practice’s Privacy Official or with the Office for Civil Rights. The address for the Office for Civil Rights is listedbelow:OFFICE FOR CIVIL RIGHTSU. S. Department of Health and Human Services"20

200 Independence Avenue, S.W.Room 509F, HHH BuildingWashington, D. C. 20201PROCEDURE AND ALTERNATIVESI.a.I authorize the medical staff at DFW Bariatric Ins.tute, to assist me in my weight loss efforts. I understand my treatment may involve theuse of one or more of the following modali.es to lose weight: a very low calorie diet (VLCD); use of appe.te suppressants for more than 12weeks, the .me period indicated in the appe.te suppressant labeling; off-label use of Megormin for treatment of obesity.b.I understand it is my responsibility to follow the instruc.ons carefully and to report to the doctor trea.ng me for my weight any significantmedical problems that I think might be related to my weight control program as soon as reasonably possible.c.I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain the weight loss. Iunderstand my con.nuing to receive the VLCD supplements, appe.te suppressant or Megormin will be dependent on my progress in weightreduc.on and weight maintenance. I am aware that weight gain may occur if I am not compliant with the program.d.I understand there are other ways and programs that can assist me in my desire to lose and maintain my weight.II.RISKS OF PROPOSED TREATMENTa.Prior to my treatment, I have fully disclosed any medical condi.ons or disease that may prevent me from receiving appe.te suppressant orVLCD for my weight loss.b.I understand this authoriza.on is given with the knowledge that the use VLCDs and appe.te suppressants may involve some increased risksand hazards such as the following:i.Side effects of VLCDs: lightheadedness, fa.gue, cons.pa.on, headache, bad breath, dry mouth, nausea/vomi.ng, diarrhea and hair loss.Less likely are gallbladder disease, allergy, fain.ng, low potassium and low sodium. In addi.on, the use of a VLCD with blood pressure and/or diabetes medica.ons could cause low blood pressure and/or low blood sugar, respec.vely. These and other possible risks could, on a rareoccasion, be serious or fatal.ii.Side effects of appe.te suppressants:

Low Carb Low Fat Hypnosis Atkins Diet Mayo Clinic Diet Richard Simons Scarsdale Diet Sugar Busters Slim Fast South Beach Diet Acupuncture Diet Pills from MD Diet Shots from MD Diet Center Jenny Craig Overeaters Anonymous Optifast / Medifast LA Weight Loss Nutri System Psychological Counse

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2 Patient Guide for Bariatric Surgery Bariatric Information Sessions Who: Any new patient considering bariatric surgery for weight loss. Feel free to bring family and friends along. When: Third Tuesday of every month fr

The value of a care map is well recognized in bariatric surgery. Current literature, while limited, does support the use of clinical care pathways in bariatric surgery. Several single institutional studies of bariatric patients demonstrate

Improvement in mortality after bariatric surgery 72 1.21 Resolution of co - morbidities after bariatric surgery 73 1.22 Bariatric surgery leads to an improv ement in glucose homeostasis 74 1.23 The economic costs of obesity can be counteracted by obesity surgery 75 1.24 Our hypoth

Bariatric Surgery Patient Binder Weight Loss Surgery Bariatric surgery, or weight loss surgery, is a tool to help people lose weight. When accompanied by permanent lifestyle changes, it can help individuals achieve lasting health benefits. Baptist Health Bariatric Center offers the lat-est and safest weight loss surgery options:

4 Fifth report of the Bariatric Surgery Registry June 2017 List of Figures Figure 1 » Rate of Obesity in Australia (1995 to 2015) 10 Figure 2 » MBS Data on Number of Bariatric Procedures in Australia 11 Figure 3 » Hospitals and Surgeons Performing Bariatric Surgery in Australia as at 30 June 2017 13 Figure 4 » Accumulation Rate of Patients Participating in the BSR by Patient Type 15

Psychological Considerations Before Bariatric Surgery (2020) Dr. Gretchen E. Ames, Ph.D . Provided to ASMBS for distribution as part of The FELLOW Project 2018 MFMER 3697160 -1 Psychological Considerations Before Bariatric Surgery Gretchen E. Ames, PhD, ABPP ASMBS Fellow Series 2018 MFMER 3697160 -2 Bariatric Team Patient Relations .

Bariatric Center HEALTH INFORMATION PACKET Thank you for choosing the Main Line Health Bariatric Center based at Bryn Mawr Hospital. In order to maximize your first visit to our office, it would be helpful if you could complete this health information packet ahead of time. You may bring it with you to the appointment, or for your convenience .