LifeBridge Health Division of Bariatric & Minimally Invasive Surgery

5401 Old Court Rd.Randallstown, MD 21133

(410) 701-4880Dear Patient:

Thank you for inquiring about our ORBERA program! Please take the time to fill out the enclosed intake form carefully and completely. Return it to the address listed above, fax to 410-701-4883, or scan and email to bariatric@lifebridgehealth.org. Please return within 24 hours for faster processing. Our staff will then contact you to give you an appointment date.

ORBERA is a nonsurgical weight loss program. It is a two-part weight loss program designed to help you lose weight and maintain a healthy lifestyle. Long-lasting weight loss and overall health is much more achievable with ORBERA, healthy diet, our support team, exercise, and access to an available after-care program.

For the entire duration of the 12-month program you will be encouraged through the help of our support team to follow a diet and exercise plan. Currently ORBERA is not covered by insurance. Our program includes 1 year access to a physician, nurse practitioner, registered dietitian, and support groups for $7,800.

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

410-701-4880 (office) 410-701-4883 (fax)Web Site: Lifebridgehealth.org/bariatricsurgery E-mail: bariatric@lifebridgehealth.org

(updated on 7/18/16)

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LifeBridge Health Division of Bariatric & Minimally Invasive Surgery

5401 Old Court Rd.Randallstown, MD 21133

(410) 701-4880ORBERA Patient Application

NAME: _________________________________ Date: __________________

Social Security No.:First Name: Middle

Initial:

Last Name:Gender: M F

Applicant’s Maiden Name:Birth Date: Current Age:Home Address:

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

Employer: Occupation:Employers Address: Length of time @ current employment: ________ Years ________ Months

Emergency Contact Information:

Name:Relationship:

Home Address:City, State, Zip:

Home Number: Cell Number : 410-701-4880 (office) 410-701-4883 (fax)

Web Site: Lifebridgehealth.org/bariatricsurgery E-mail: bariatric@lifebridgehealth.org(updated on 7/18/16)

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LifeBridge Health Division of Bariatric & Minimally Invasive Surgery

5401 Old Court Rd.Randallstown, MD 21133

(410) 701-4880

Work Number:NAME: _________________________________

Family/Friend Insurance Internet

Magazine Newspaper Primary Care Physician

TV Orbera website Other:________________

I heard about LifeBridge Bariatric Surgery through:

Name:Phone Number:Fax Number:

Primary Care Physician Information:

Weight: Height: BMI:

Drug Allergies: Check if no allergiesMedication Allergies Type of reaction

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

Medication Strength Frequency Purpose

Started(Initials /Date)

Stopped (Initials /Date)

410-701-4880 (office) 410-701-4883 (fax)Web Site: Lifebridgehealth.org/bariatricsurgery E-mail: bariatric@lifebridgehealth.org

(updated on 7/18/16)

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LifeBridge Health Division of Bariatric & Minimally Invasive Surgery

5401 Old Court Rd.Randallstown, MD 21133

(410) 701-4880

410-701-4880 (office) 410-701-4883 (fax)Web Site: Lifebridgehealth.org/bariatricsurgery E-mail: bariatric@lifebridgehealth.org

(updated on 7/18/16)

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LifeBridge Health Division of Bariatric & Minimally Invasive Surgery

5401 Old Court Rd.Randallstown, MD 21133

(410) 701-4880NAME: _________________________________

Surgical History (all that apply): r Check if no surgical historySurgery 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) : Hospital Admissions:

Comorbid Conditions (all that apply):

Anxiety DVT Migraines/Headache

Arthritis Fibromyalgia Peripheral Edema(Swelling of the legs)

Asthma High blood pressure Pneumonia

Bronchitis Hypercholesterolemia(High cholesterol)

Reflux Disease(Heartburn or severe indigestion)

Chest Pains Hypertriglyceridemia(High triglycerides) Seizure

CHF Hyperthyroidism Sleep ApneaDiagnosed Observed

Depression Hypothyroidism Stress Incontinence Diabetes Type I (Insulin dependent) Leg Ulcers Superficial Phlebitis Diabetes Type II (Non-insulin dependent) Lower back pain Varicose Veins

Please bring a valid ID at the time of appointment.

410-701-4880 (office) 410-701-4883 (fax)Web Site: Lifebridgehealth.org/bariatricsurgery E-mail: bariatric@lifebridgehealth.org

(updated on 7/18/16)

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