Patient Questionnaire

This form in intended for patients who are concerned that the wait for bariatric surgery in the public system may worsen their health and wish to pay and have their surgery at our private hospital at a time of their choosing.

It is not intended for patients who wish to place their name on the public system wait list-SIMASS .

PATIENT QUESTIONNAIRE

Please list all your phone numbers and the best time and phone number to call you (eg. 8 pm at home or 2 pm at work or anytime on my cell)
GENERAL INFORMATION
PERSONAL HABITS


FOR WOMEN ONLY
YOUR CURRENT HEALTH STATUS






(Click the best match and give details of medication later)









(Click all that apply)












(Check all that apply)
























(Click all that apply and give details at the end if needed)
PAST SURGICAL HISTORY








(Click all that apply and give details at the end if needed)





(Click all that apply and give details at the end if needed)
MEDICATION HISTORY
(If YES give details in the Medication box below)
(If YES give details in the Medication box below)
(If you are not taking any medications just enter "None")








(Click all that apply)
AGREEMENT

I understand that I am requesting surgery in the private sector and that I will have to pay for this surgery.

I understand that Weight Loss Surgery and its suppliers of services will collect personal information relating to me in order to prepare and carry out my surgery and to invoice me the expenses, costs and fees which correspond to it.

I understand that the file containing my personal information will be preserved by Weight Loss Surgery or its suppliers of services at their offices or on their electronic servers and that their employees who require it in the performance of their duties will have access to this file.

I grant this collection and use of my personal information for this purpose. I hereby authorize Weight Loss Surgery Inc. to disclose my individually identifiable health information to the bariatric surgeons and staff of Weight Loss Surgery. This information will be used to assess my candidacy for bariatric surgery and allow the team to provide all preoperative, operative and post-operative care.

I understand that both Weight Loss Surgery Inc. and its bariatric surgeons and staff agree to abide by the NOTICE OF PRIVACY PRACTICES which is available for inspection at any time.