Pre-Screen Assessment

Prior to surgery, your first step is to attend an informational seminar. After you've completed that step, you may choose to complete this bariatric pre-screening assessment.

Your Information

Name
Address
Date of Birth*
Marital Status

Insurance Information

Policy Holder Name
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Medical History

Have you ever been diagnosed with or suffered from any of the following? (Please choose all that apply)*
Have you been a patient at NKCH?
Have you previously had weight loss surgery?
Were you referred by your physician?*
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Date/Time Submitted*
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