Skip to main content
Explore URMC

Highland Hospital Logo

menu

Patient Forms

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
    Box 95
    Rochester, NY 14620
  • Drop off at the Highland Hospital Bariatric Surgery Center registration desk