- wujac Forms

Pre-Seminar Washington University Bariatric "Weight Loss" Form

Full Legal Name

Maiden Name

Date of Birth

Gender at Birth

Male

Female

Perfer not to answer

Gender you identify with

Male

Female

Perfer not to answer

Preferred Language

Social Security Number

Cell Phone Number

Work Phone Number

Land Line Number

Address

City

State/Province

Zip/Postal

Country

Emergency Contact Name

Emergency Contact Phone

Relationship to Emergency Contact

Height

Weight

BMI (office use only)

Check all that apply to you. Please note a diagnosed co-morbid condition may be required by insurance and/or our program.

Diabetes

Heart Disease

Sleep Apnea

High Blood Pressure

Other

None

Are you seeking revision of previous weight loss surgery?

Yes

If YES, what was your original surgery?

Adjustable gastric band

Sleeve gastrectomy

Roux-en-Y gastric bypass

Duodenal switch

If YES, when was the surgery performed?

Primary Physician (first/last)

Physician Phone

Physician Address

Address

City

State/Province

Zip/Postal

Country

I do not have a Primary Care Physician.

Referring Physician (first/last)

Referring Physician Phone

Referring Physician Address

Address

City

State/Province

Zip/Postal

Country

My referring physician is the same as my Primary physician.
I do not have a "referring physician." I am "self" referring.

Primary Insurance Name

Primary Insurance Phone

Primary Insurance Address

Address

City

State/Province

Zip/Postal

Country

ID Number

Group Number

Policy Holder Employer

BJC/Wash. U

Other

Policy Holder Relation

Spouse

Parent

Self (if 'Self,' skip 'Secondary Insurance')

Policy Holder Name

Policy HolderDate Of Birth

Policy Holder Address if different from patient

Address

City

State/Province

Zip/Postal

Country

If Tri-Care insurance - Branch & Member ID SSN

Please call insurance. Is weight loss surgery covered?

Yes.

No, I will self pay.

Secondary Insurance Name

Secondary Insurance Phone

Secondary Insurance Address

Address

City

State/Province

Zip/Postal

Country

ID Number

Group Number

Policy Holder Employer

BJC/Wash. U

Other

Policy Holder Relation

Spouse

Parent

Self (if 'Self,' skip 'Secondary Insurance')

Policy Holder Name

Policy HolderDate Of Birth

Policy Holder Address if different from patient

Address

City

State/Province

Zip/Postal

Country

If Tri-Care insurance - Branch & Member ID SSN

Please call insurance. Is weight loss surgery covered?

Yes.

No, I will self pay.

I do not want to add a secondary insurance.