Division of Bariatric Surgery

LifeBridge Health

Division of Bariatric Surgery

5401 Old Court Road

Randallstown, MD 21133

Dear Patient:

Thank you for inquiring about our weight loss surgery program! The decision to undergo weight loss surgery is not a decision you made quickly; in a similar fashion, the process of preparing you for surgery also cannot occur quickly, nor be rushed. Please take the time to fill out the enclosed intake form carefully and completely. Remember to attach a legible copy of your picture ID along with your medical insurance card (front & back). Our staff will then contact you to give you an appointment date, usually within two weeks of receipt of your application.

In the meantime, we encourage you to attend our monthly informational seminars and/or webinars. We will be present at each seminar, as well as, members from our staff and post-op patients. Everyone is invited to attend, be sure to verify the dates on our website at or call (410) 601-4486.

Most insurance companies require that policy holders be seen monthly for 3-6 consecutive months to document weight loss attempts and progress. Therefore, as an insurance and program requirement we require patients to see the Registered Dietitian at either Sinai Hospital or Chartwell Professional Center. Adherence to the program greatly increases your success following bariatric surgery. Both programs adhere and teach the same nutritional information concerning food choices and surgery

Prior to being seen at one of the LifeBridge Health centers ask your Primary Care Physician (PCP) for a request for consultation. If a referral is required with your insurance plan, please make sure we have an updated referral on file. All co-payments are due at the time of service. PLEASE NOTE we only accept cash, Visa, and/or MasterCard for payment at Sinai Hospital. We only accept cash or checks at our other locations.

Your insurance plan will likely require extensive testing to ensure that they will approve the surgery. If you prefer, you can obtain some of this BEFORE your initial consultation. The following are required by ALL insurance companies of all patients prior to scheduling surgery:

1)Proof of attendance at a minimum of one of our bariatric seminars or webinars.

2)A letter from your primary care physician. This letter should summarize your diet history, your obesity-related medical problems and any physician-supervised weight loss attempts that you have had. It should also include a sentence or two stating that your physician feels that you are a good candidate to undergo surgery.

3)Psychology/psychiatry clearance. All patients are required to undergo a psychological evaluation prior to surgery, so that we can document adequate knowledge of the procedure, reasonable weight loss expectations, and the ability to comply with the rigorous dietary restrictions post-operatively. You can obtain clearance from your own psychologist or psychiatrist if you prefer.

Every patient will require additional pre-operative testing, these tests will be ordered on an individual basis after you have met with one of the surgeons. If you have any questions about LifeBridge Health Bariatric Surgery Program and our locations, please contact us at 410 601-4486 and one of our staff will be glad to help you.

We look forward to meeting you and helping you reach your goal of a healthy weight and healthier lifestyle.

Christina Li, MD, FACS Celine Richardson, MD. FACS

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AVOID these medications 2 weeks prior to surgery and call the office before taking any new medication for pain management

Aspirin Products:
Aggrenox
Alka-Seltzer (Effervescent pain reliever and antacid, lemon-lime effervescent pain reliever and antacid, extra strength effervescent pain reliever and antacid, Morning relief)
Anacin (maximum strength)
Ascriptin (enteric regular strength, regular strength, arthritis pain)
AsperDrink
Aspergum

Aspirin/butalbital/caffeine

Aspirin with buffers
Aspirtab
Aspir-Trin
Bayer (Children’s Chewable, Adult Low Strength, Genuine Bayer, regular strength caplets, women’s aspirin plus calcium caplets, extra strength back and body pain)
BC Powder (arthritis strength)
Bismuth Subsalicylate (Pepto
Bismol, Kaopectate, Bismatrol, Kola-Pectin, Diotame, Kapectolin, Bismate, Bismakote, Bismuth, Stomach Relief, Kao-Tin, Kensorb, Kao-Paverin, Peptic Relief, Sootheze)
Bufferin (arthritis strength, extra strength)
Carisoprodol Compound (with codeine)
Citrated/Aspirin/caffeine
Cope
Damason-P
Easprin / Aspirin Products:
Ecotrin (Adult Low Strength, Maximum Strength)
Ecprin
Endodan
Entercote
Equagesic
Excedrin (extra-strength, migraine)
Fiorinal
Fortabs
Gelprin
Genacote
Goody’s (body pain formula powder, extra strength headache powders, extra strength pain relief tablets)

Halfprin

Orphenadrine P-A-C analgesic
Magnesium salicylate (Doan’s, Backprin, Keygesic, Momentum, Agesic, Mobidin, Novasal, Pamprin)
Magnaprin (Improved, arthritis strength)
Micrainin
Miniprin
Norgesic (Forte)
Norwich Aspirin
Pamprin
Percodan
Robaxisal

Soma

Stanback Powder
St.Joseph (Adult Low Strength chewable, Adult Low Strength enteric coated tablets)
Store brands (Good Neighbor Pharmacy, Good Sense, Leader, Medi-First, Quality Choice, Top Care, Rite Aid) / Synalogos-DC
Trilisate
Vanquish

Zorprin

NSAIDS products:
Diclofenac (Flector, fcataflam, Voltaren, Arthrotec, Cataflam, Cambia)
Diflunisal (Dolobid)
Etodolac (Lodine)
Fenoprofen (Nalfon)
Flurbiprofen (Ansaid)
Ibuprofen (Advil, Motrin, Genpril, Haltran, Menadol, Midol, Vicoprofen, Dristan)
Indomethacin (Indocin)
Ketoprofen (Oruvail, Orudis)
Ketorolac (Toradol, Acular, Acuvail, Sprix)

Meclofenamate

Mefenamic (Ponstel)
Meloxicam (Mobic)
Nabumetone (Relafen)
Naproxen (Naprosyn, Prevacie Napra PAC, Aleve, Naprelan, Anaprox)
Oxaprozin (Daypro)
Piroxicam (Feldene)
Salsalate(Disalcid, Amigesic, Salflex, Persistin, Mono-gesic, Marthritic, Arthra-G, Argesic-SA)
Sulindac (Clinoril)
Tolmetin (Tolectin)

Cox-2 Inhibitors

Celecoxib (Celebrex)

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Application Process

1.Call your insurance company and complete the Insurance Verification form on page 4.

2.Complete the Patient Application on pages 5 - 13 and the Nutritional Assessment on pages 15 – 18.

3.Return the Insurance Verification, Patient Application, and the Nutritional Assessment to our office (pages 4 – 18).

1. Please keep the folder & resource papers in the right sleeve.

4.Our office staff will verify your insurance benefits.

5.One of the physicians will review your application.

6.Our office staff will call you to schedule an initial appointment with the physician and dietitian.

1. Reminder: the nutritional consultation has a mandatory program fee (not covered by any insurance) which is due at the initial appointment.
2. All self-pay portions are due at the time of service.
3. We accept only cash or credit cards as payment. We do not accept checks.

7.Please allow 1-2 weeks, plus mailing time for our staff to contact you.

8.While waiting to hear from our office you can complete the following steps:

1. Contact your Primary Care Physician for any necessary referrals per your insurance requirement. (Some offices require 1-2 weeks notice to have referrals ready).
2. Attend one of our bariatric seminars/webinars (see enclosed flyer for dates).

Please include copy of driver’s license and insurance card (front & back) with application

Insurance Verification Form

Call to verify insurance coverage for bariatric surgery. The telephone number is located on the back of your insurance card. This completed form must be submitted with your application.

First Name: / Middle Initial:
Last Name: / Birth Date:
Insurance Company:
Insurance Phone No.:
Date Insurance Company Called:______ / Spoke with:______
Type of Plan: HMO / POS / PPO / MCO / Medicare / Other: ______
Policy No.: ______ / Group No.: ______ / Effective Date: ______
Ask your insurance representative the following questions:

1. Is this a small group policy?

/ Yes No

1. Does this policy have ANY exclusion for Bariatric Surgery or Morbid Obesity?

/ Yes No

1. Does the insurance cover the following procedures:
2. Gastric Bypass (CPT 43644)
3. Gastric Banding (CPT 43770)
4. Sleeve Gastrectomy (CPT 43775)

/ Yes No
Yes No
Yes No

1. Is this procedure subject to any pre-existing conditions on the policy? If yes, please list ______

/ Yes No

1. Are there specific criteria that need to be met in order to qualify for this surgery? If yes, please list:
2. Total months of consecutive supervised weight loss
3. Other: ______

/ Yes No _____ months

1. Do you need a referral from your Primary Care Physician to see the specialist?

/ Yes No

1. Is there a co-pay to see the Specialist?
2. What is the co-pay?

/ Yes No
$ ______

1. Do you have a deductible?
2. What is the amount?
3. How much of the deductible has been met?

/ Yes No
$ ______
$ ______
Please include a copy of your driver’s license and insurance card (front & back) with the application

Patient Application

NAME: ______Date: ______

I am interested in having:
-CHOOSE A PROCEDURE - / I am interested in seeing the doctor & dietitian:
-CHOOSE A LOCATION -
Gastric Bypass / NorthWest Hospital Center
Sleeve Gastrectomy / Sinai Hospital
Laparoscopic Band / Dorsey Hall- Ellicott City, MD
First Name: / Middle Initial:
Last Name: / Gender: / M F
Social Security No.:
Birth Date: / Current Age:
Weight: / Height: / BMI: / (If known)
Mother’s Maiden Name:

Contact Information:

Home Address: / Apt/Unit #:
City: / State: / Zip:
E-mail:
May we contact you at this number?
Home Number: / Yes / No / Preferred
Cell Number: / Yes / No / Preferred
Work Number: / Yes / No / Preferred
Employed: / Yes / No / Full Time / Part Time Retired Disabled
Employer: / Occupation:
Employers Address:
Length of time @ current employment: ______Years ______Months

NAME: ______

Emergency Contact Information:

Name: / Relationship:
Home Address: / City, State, Zip:
Home Number: / Cell Number:
Work Number:

Pharmacy Information:

Pharmacy Name: ______
Address: ______ / City, State, Zip: ______
Phone Number: ______ / Fax Number:______
Primary Care Physician / Other Physician
Name:
Specialty:
Address:
Address 2:
City:
State:
Zip:
Phone Number:
Fax Number:

Physician Information:

NAME: ______

Insurance Information:

Primary Insurance / Secondary Insurance
Insurance Carrier Name:
Group Number:
ID Number:
Policyholder’s Name:
Policyholder’s DOB:
Policyholder’s SS#:
Relationship to Insured:
Insurance Address:
City, State, Zip:
Phone Number:
Fax Number:

I heard about Sinai Bariatric through:

 Family/Friend
 Insurance
 Internet /  Magazine
 Newspaper
 Primary Care Physician /  TV
 Other:

NAME: ______

The doctor will complete this section.
CC: Morbid obesity
HP: This is a ______year old male/ female G __ P __ A__ morbid obese patient interested in bariatric surgery. His/Her current weight is _____ lbs. and a height of ____ resulting in a BMI of _____. His/Her ideal weight should be _____ lbs. for a BMI of 25. His/Her excess weight has been calculated to be _____ lbs. He/She has been unable to control or reduce their weight by medical management.

Medical History (all that apply):

Anxiety / Fibromyalgia / Reflux Disease (Heartburn or
severe indigestion)
Arthritis / Heart Attack / Seizures
Asthma / High blood pressure
(Hypertension) / Sleep Apnea
Diagnosed Observed
Bronchitis / Hypercholesterolemia
(High cholesterol) / Snore
Cancer / Hypertriglyceridemia
(High triglycerides) / Stress Incontinence
Cardiac Surgery / Hyperthyroidism / Stroke
Chest Pains / Hypothyroidism / Varicose Veins
CHF / Leg Ulcers / Other :
Depression / Lower back pain
Diabetes Type I
(Insulin dependent) / Migraines/Headache
Diabetes Type II
(Non-insulin dependent) / Peripheral Edema
(Swelling of the legs)
DVT (Leg Blood Clots) / Pneumonia

NAME: ______

Surgery / Date / Comment
C section / Number:
Gall Bladder / Open / Laparoscopic
Hernia / Hiatal / Inguinal / Incisional / Umbilical
Hysterectomy / Abdominal / Vaginal
Obesity – previous / Band / Gastric By-pass / Sleeve
Orthopedic / Type:
Tubal Ligation
Other (list surgeries and year) :

Surgical History (all that apply):Check if no surgical history

Hospital Admissions:Check never been admitted to the hospital

Hospital / Date / Reason

NAME: ______

Health History (all that apply):

HEAD AND NECK
N/A / Change in vision / Ringing in ears / Nosebleeds
Double vision / Dizziness / Hoarseness
Deafness / Sinusitis / Other
CARDIOVASCULAR
N/A / Palpitation / Leg pain w/ walking / High cholesterol
Chest Pain / Heart disease or Attack / High Blood Pressure
Leg Swelling / Other (please list):
RESPIRATORY
N/A / Cough / Asthma/Bronchitis / Shortness of Breath
Wheezing / Sleep Apnea
Diagnosed Observed / Other (please list):
GASTROINTESTINAL
N/A / History of Ulcers / Abdominal pain / Changes in bowel habits
Difficulty w/ swallowing / Vomiting / History of blood transfusion
Nausea / Bloody Stools / History of polyps
Heartburn/Reflux / Jaundice / Other (please list)
URINARY
N/A / Difficulty urinating / Stress incontinence / Frequent UTI/Kidney Infections
Urinating at night / Kidney stones / Other (please List)
NEUROLOGIC
N/A / Numbness or tingling / Weakness / Other (please list)
Seizures / Previous Stroke
ORTHOPEDICS
N/A / Back pain / Arthritis / Difficulty walking
History of fractures / Body Aches / Other (please list)
PSYCHIATRIC
N/A / Panic attacks / Sleeping difficulties / Bipolar disorder
Chronic depression / Attempted suicide / Other (please list)
ENDOCRINE
N/A / Thyroid Problems / Hair Loss / Other (please list)
Menstrual Problem / Diabetes
Insulin Non-Insulin
HEALTH SCREENING
N/A / Last Mammogram / Last Pap Smear or Prostate exam / EGD (date)______
Colonoscopy (date)______
HEMATOLOGY
N/A / Anemia / Enlarged lymph nodes / Other (please list)
Bleeding / History of cancer
IMMUUNOLOGIC
N/A / HIV / Hepatitis B or C / Other (please list)
Other (please list)

NAME: ______

Drug Allergies: Check if no allergies

Medication Allergies / Type of reaction

Current medication (prescription and non-prescription): Check if no medications

Medication / Strength / Frequency / Purpose / Started
(Initials /Date) / Stopped(Initials /Date)

Social History:NAME: ______

Marital Status:
Single
Married
Divorced
Separated
Widowed / Ethnic Origin:
Black/African American
Hispanic
White/Caucasian
Asian/Oriental
Other: / Education:
9 to 11 years
High School Graduate/GED
Vocational/Technical
Some College
College Graduate
Post Graduate Degree / Number of Children:
None
1
2
3
4
5 or more
Religion:
Catholic
Jehovah Witness
Jewish
Prostestant
Other (List): ______ / Do you use tobacco products?
If yes, what kind:
Cigarettes
Cigars
Chewing tobacco / Yes Never Smoked
Former Smoker
If yes, how much:
1/2 pack or less per day
Between 1 – 1.5 packs per day
Between 1.5 – 2 packs per day
2 packs or more per day
Do you drink alcohol? Yes
If yes, how much:
Less than 2 per day
Between 2 – 5 per day
Between 6 – 10 per day
More than 11 per day / No
If yes, how often:
Daily
Weekly
Monthly
Occasionally / Have you ever used illegal drugs? Yes No
If yes, what kind:
Marijuana
Cocaine
Heroin
Amphetamines / If you still use drugs, how often:
Daily
Weekly
Monthly
Occasionally

List the diets/programs have you have tried within the last 5 years:

Diet or Weight Loss Medication / Year / Length in Months / Number of Pounds Lost
What age were you considered obese?
What was your lowest adult weight?
What is your desired weight?

Check if you have used the following medications to lose weight:

 Phentermine
 Phen-Fen /  Orlistat (Xenical)
 Meridia /  B-12 shots
 Other

Check the eating behaviors which have contributed to weight gain:

Skipped meals / Frequent sweets / Vomiting after large meals
Large portions / High carbohydrate diet / Frequent snacking
Fatty foods / Binge eating / Fast foods
Emotional eating / Laxative use / Other:
Weight / Health Problems
Mother / Diabetes
Heart Disease
High BP
High Cholesterol / Sleep Apnea
Joint Disease
Stroke
COPD / Obesity
Reflux Disease
Lupus
 Other:
Father / Diabetes
Heart Disease
High BP
High Cholesterol / Sleep Apnea
Joint Disease
Stroke
COPD / Obesity
Reflux Disease
Lupus
Other:
Maternal
Grandmother
(Mother’s Mother) / History of Cancer/Type
______
Maternal
Grandfather
(Mother’s Father) / History of Cancer/Type
______
Paternal
Grandmother
(Father’s Mother) / History of Cancer/Type
______
Paternal
Grandfather
(Father’s Father) / History of Cancer/Type
______
Sibling
Brother
Sister / Diabetes
Heart Disease
High BP
High Cholesterol / Sleep Apnea
Joint Disease
Stroke
COPD / Obesity
Reflux Disease
Lupus
Other: / Rheumatoid Arthritis
Sibling
Brother
Sister / Diabetes
Heart Disease
High BP
High Cholesterol / Sleep Apnea
Joint Disease
Stroke
COPD / Obesity
Reflux Disease
Lupus
Other: / Rheumatoid Arthritis
Sibling
Brother
Sister / Diabetes
Heart Disease
High BP
High Cholesterol / Sleep Apnea
Joint Disease
Stroke
COPD / Obesity
Reflux Disease
Lupus
Other: / Rheumatoid Arthritis
Sibling
Brother
Sister / Diabetes
Heart Disease
High BP
High Cholesterol / Sleep Apnea
Joint Disease
Stroke
COPD / Obesity
Reflux Disease
Lupus
Other: / Rheumatoid Arthritis

Family History: NAME: ______

Additional Information

• HMO’S, POINT OF SERVICE, AND MANAGED CARE PLANS:

If your insurance company is an HMO, point of service, or managed care plan, you must obtain a written out-of-network referral before your consult with the surgeon. You must follow the rules of your insurance company in order to obtain the highest level of benefits. Your primary care physician’s office will need to contact the insurance company for a referral. You may make an appointment with the surgeon; however, the referral must be received or brought with you to the appointment.

• SELF PAY PATIENTS:

If your insurance does not cover weight loss surgery and you wish to proceed as a cash patient, please contact the office for fees and scheduling information.

• DIETITIAN FEE:

A dietitian fee is required at your initial appointment. This fee is non-refundable.

• PAIN MEDICINE:

Do not take any “pain medication/anti-inflammatories” three weeks prior to surgery without consulting with your surgeon (see list on page 2). Most pain medicines increase the chance of bleeding. This may result in cancellation of your procedure.

IMPORTANT NOTICES

We only accept cash or credit card as acceptable form of payment.

We require 24 hour notice if you are unable to keep your scheduled appointment. A fee of $25 will be billed to you for each missed appointment.

Nutrition & Eating Habits Questionnaire