Bariatric Questionnaire – Step 1

Bariatric Questionnaire – Step 1

Click here to print out the form:

The information you provide will help us to plan your treatment, please carefully fill out and sign the last page.

PERSONAL DETAILS

Only candidates with a body mass index of 35 or less





ADDRESS

















PRIMARY HEALTHCARE PROVIDER













CONTACT PERSONS

This information is often vital to us if we need to contact your family urgently. Occasionally people move or have new phone numbers and do not let us know.



1. NEXT OF KIN:





ADDRESS










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