Use this checklist as a guide to help you be approved for surgery.
Download the Bariatric Journey Map
Before your History and Physical Appointment can be scheduled, the following forms need to be completed and returned.
Bariatric Surgery Questionnaire
This form should be completed by the patient
Primary Care Physician Form
This form should be completed by the patient's Primary Care Physician
Prior to your surgery, please complete and return the following form.
Release of Information Form
This form should be completed by the patient prior to surgery as part of the disability process.
How to Return the Completed Forms
Choose any of the following options:
- Bring to the Seminar
- Fax to (585) 341-0215
- Mail to:
Department of Surgery
c/o Bariatric Surgery Questionnaire
1000 South Avenue
Rochester, NY 14620
- Drop off at the Highland Hospital Bariatric Surgery Center registration desk