New Patient Intake Form Bariatric Surgery Any additional information can be sent to admin@lasvegasdietitians.com Patient Information Name * First Name Last Name Date Of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Bariatric Surgeon/Office Anticipated Date of Surgery MM DD YYYY How many sessions with an RD are you required to have? Insurance Primary Insurance Plan Type PPO HMO MEDICARE MEDICAID Primary Insurance ID # Secondary Insurance Plan Type PPO HMO MEDICARE MEDICAID Secondary Insurance ID# Additional Information * Please attach a copy of your insurance and ID below. Our office verifies insurance coverage prior to your appointment. I understand patients are required to provide at least 24- hour notification if an appointment needs to be rescheduled or cancelled. A "No-Call, No-Show" appointment will be subject to a $25 Cancellation fee. * I Agree Thank You!We look forward to seeing you at the time of your appointment. Please send any additional information to admin@lasvegasdietitians.com
