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Patient Forms

Download this checklist to help guide you to be approved for surgery.

The Bariatric Journey Map

 

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:

  • 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