Before your History and Physical Appointment can be scheduled, please complete the following form.
Bariatric Surgery Questionnaire
This form should be completed by the patient
Before your first scheduled appointment, please ask your Primary Care Physician to complete and return the following form.
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:
- Mail to:
Department of Surgery
c/o Bariatric Surgery Questionnaire
1000 South Avenue, Box 95
Rochester, NY 14620
- Drop off at the
Bariatric Surgery Center