Emmc Surgical Weight Loss Program Referral Form
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1EMMC Surgical Weight Loss Program Referral Form
DOB:
/
/
Patient Name:
Social Security#___________________________________________________________________________________
Address:
City/Zip:
Phone: (H)
(W)
(Cell)___________________________________
Primary Insurance (PLEASE SEND COPY OF CARD):
Name/certificate/group#___________________________________________________________________________________
_____________________________________________________________________________________________________
Secondary Insurance
Name/certificate/group#___________________________________________________________________________________
______________________________________________________________________________________________________
Relative contraindications to gastric bypass surgery (please check ):
Smoking* Yes or No
Repeated no-shows for scheduled office visits
Significant psychiatric diagnosis
Active drug/alcohol/prescription narcotic abuse**
*As of 08/08 we can no longer accept referrals on patients who smoke. Your office must provide documentation regarding
smoking cessation before we can begin the program.
Pt. Height:
Pt. Weight:
Body Mass Index:
___
Indications for referral:
Morbid obesity (Body Mass Index > 40)
Obesity (Body Mass Index 35-39.9 with 1 of the following :heart disease, type 2 diabetes, poorly controlled
HTN, obstructive sleep apnea (latter two must be treated)
Comorbid Diagnosis:
Diabetes (Last HgA1C=
)*
Cardiovascular disease
Hypertension
Fatty Liver
Venous stasis ulcers/cellulitis
Hyperlipidemia
Chronic pain (please indicate where:________________________)
GERD
Osteoarthritis
Sleep apnea (If checked please indicate current treatment_________________________________________)
PCOS
Other:________________________________________________
*HbA1C must be < 8 to proceed to surgery
Past treatments for weight loss/control:
Diet therapy (documented attempts at therapy by MD, DO, PA, NP, RD)
Weight Loss Medications (please list:
)
Prior weight loss surgery; What year________________What surgery: _____________________________
(operative reports or discharge summaries helpful if the patient has had prior weight loss surgery. May need UGI
study to determine if reoperation is an option).
Present Medications:
Please send medication list
Procedure Requested:
Gastric Bypass Surgery
Adjustable Gastric Band
Sleeve Gastrectomy
Bariatric Surgeon Preference (leave blank if no preference):
Dr. Fariba Dayhim
Dr. Michael St. Jean
Dr. Michelle Toder
With this referral and my signature I authorize the following evaluations prior to surgeon consult and surgery:
1.
Med. Nutrition Therapy 2. Psychological Evaluation 3. Physical Therapy Evaluation/Treatment
4. Split-Study polysomnography and sleep apnea treatment as indicated (screening protocol completed by SWLP personnel and
Appointment coordinated by SWLP)
Printed Name: ________________________________
Signature of the Referring Provider:
Phone #:
Fax #:
Date of referral: _______________________________
Mail /fax this form along with a recent H/P and OV notes to:
SWLP, 905 Union Street, Suite 11, Bangor, ME 04401: Phone 973-6383 Fax 973-7364
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