Welcome to the Center for Surgical and Medical Weight Loss. Thank you for choosing our Center at Saint Thomas for your weight loss journey.

Transcription

1 Welcome to the Center for Surgical and Medical Weight Loss. Thank you for choosing our Center at Saint Thomas for your weight loss journey. Once your initial appointment has been scheduled, you will receive two s: One will include this New Patient Packet (required) and a link to our online seminar (highly recommended) to be completed prior to your initial appointment. Another will prompt you to check-in on Phreesia, which is separate from the new patient packet and will be required in addition to the New Patient Packet. We strongly encourage patients to sign up for the Patient Portal to have viewing access to your personal healthcare information such as, lab results. Important Please Bring this patient information packet COMPLETED to your appointment along with a copy of your driver s license and your insurance card, both front and back. If the packet is not completed, you must arrive 30 minutes *early before your appointment to complete. If you do not arrive early enough to fill out the packet, your appointment will have to be rescheduled to another day. If your appointment is at 8:00 a.m., you must bring a completed packet. The Center does not open until 8:00 a.m., and there will not be any time to complete it. Ensure you have viewed the on-line seminar ( which is 20 minutes. If you did not give your insurance information at the time you scheduled your appointment, complete the short form that will appear at the end of the on-line seminar and submit. This will allow our Insurance Specialists to verify if you have bariatric benefits prior to your appointment. If you already provided your insurance information by phone, you may disregard the form and exit from the on-line seminar. If you do not have access to the internet, you may arrive 45 minutes early to view the seminar at the Center. For both completion of packet and seminar viewing, arrive 60 minutes early. What to Expect Your first appointment will last approximately 60 to 90 minutes. During your first appointment, you will meet with our Patient Advocate for a free screening. You will learn about our program and its steps, and review the criteria your insurance company requires you meet for surgery approval. If you do not have bariatric insurance benefits, information on discounted self-pay fees and financing options will be provided. You will also be meeting with our Nurse Practitioner for a Medical History and Physical Exam, review of your completed packet, and to discuss your surgical options. 1

2 At the end of your appointment you will have the option of staying to complete your psychological test or you may schedule it for another day. Please note the cost of the test is $30 and is due at the time of the test. Directions to the Center for Surgical and Medical Weight Loss 2021 Church Street Medical Plaza II, Suite 104 lobby level (L) Nashville, Tennessee If you are traveling on I-65 Northbound or I-24 Westbound: 1) Follow signs to I-40 West. 2) Exit at Church Street/Charlotte Pike - exit 209 3) Take LEFT onto Church Street once you exit off the ramp 4) Turn LEFT onto 21 st Avenue (one way street) 5) When you come to the stop sign, take a LEFT onto Hayes Street 6) On your left, there will be a Parking Garage; take a LEFT into the first entrance of the parking garage If you are traveling on I-40 Eastbound: 1) Exit at Charlotte Pike - exit 209 2) Turn RIGHT at the bottom of the exit ramp onto Charlotte Pike 3) Turn LEFT onto 21 st Avenue (one way street); cross over Church Street at the traffic light 4) When you come to the stop sign, take a LEFT onto Hayes Street 5) On your left, there will be a Parking Garage; take a left into the first entrance of the parking garage Parking Garage Directions Parking is free and the garage is located off of Hayes Street called the Plaza Garage. When you enter the parking garage, choose a space that is most convenient. There is also free valet service (gratuity is optional) at the Plaza II, circular entrance off of Hayes Street. Take the elevator or the stairs to Level L. Once you exit the stairs or the elevator, you will see 2 glass doors that enter into the main lobby of the Medical Plaza. Enter through those doors. Our office is straight ahead, past Elite Physical Therapy. We are in Suite 104. Please make a note on which level you parked in the garage. 2

3 Metabolic Assessment Form Patient Name: Date of Birth: Age: Sex: SS#: - - Allergies: Emergency Contact: Relation: Phone: Social History: Occupation: Status (circle one): Full time/part time/retired/disabled Marital Status: Single Married Domestic Partnership Divorced Widowed Do you have children? YES NO If so, please list their ages: Do you smoke and/or use vapor cigarettes (e-cigarettes)? YES NO Are you a former smoker and/or user of vapor cigarettes (e-cigarettes)? YES NO Do you consume alcohol? YES NO Do you exercise on a routine basis? YES NO Do you have any religious and/or cultural concerns that we should be aware of? YES NO If yes, please explain: What is your personal motivation for having weight loss surgery? (If you have already had surgery, please skip to next section.) Weight History: (Please check any programs that you have attempted.) Exercise programs Prescription medications Over the counter medications Weight Watchers Jenny Craig Optifast Nutrisystem Atkins None Others: Which diet were you most successful with? What has been your highest weight? What is the most weight you have ever lost? Do you have any obstacles to physical activity / exercise? Please complete if you have not yet had surgery: Who will be with you on the day of surgery? Name: Relation: May we keep them updated regarding your care? YES NO 3

4 Past Medical History: (Please check yes or no for each condition.) Medical Condition YES NO Cancer, Type: High Blood Pressure Heart Disease High Cholesterol Diabetes Sleep Apnea Arthritis Acid Reflux History of Blood Clots Other: Family History: (Please indicate Yes/No, family member for each) Medical Condition Y/N Family Member Cancer, Type: High Blood Pressure Heart Disease High Cholesterol Diabetes Sleep Apnea Arthritis Acid Reflux History of Blood Clots Is your father living? YES NO If no, cause and date of death: Is your mother living? YES NO If no, cause and date of death: Name of Primary Care Physician: Name of PCP Practice: PCP Office Phone: Preferred Pharmacy Name: Pharmacy Phone #: 4

5 Current Medications: (Please list all current medications, vitamins, and minerals OR attach a complete list) Name of medication Dosage Name of medication Dosage Surgical History Type of Surgery Laparoscopic or Open? Year Use back for additional space. FOR STAFF ONLY (complete or attach Tanita slip) Height: Weight: BMI: BP: HR: 5

6 Short Term Disability / Family and Medical Leave Act (FMLA) Physician Statement Requests Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12 month period for certain reasons. Among those reasons: To care for the employee s spouse, child or parent who has a qualifying serious health condition; For the employee s own qualifying serious health condition that makes the employee unable to perform the employee s job; Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is or will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary. For additional information: U.S. Department of Labor or call USWAGE. Requests for completion of FMLA Physician Statement regarding bariatric surgery must be submitted hard copy to Mekhael Nugent, CMA, at least 30 days in advance of the Patient s projected month of surgery. A patient s projected month of surgery is determined by the Program s Patient Advocate and the patient upon entering the Program. For example, if the patient s projected surgery month is in March, the request must be submitted to Mekhael in early February. Please ensure the person requesting FMLA leave has completed all employee sections prior to submitting it to Mekhael. After the patient s pre-operative appointment with the surgeon (about two weeks prior to surgery), the completed Physician Statement is faxed by Mekhael to the HR entity. Fax confirmations are kept by Mekhael. She will fax a maximum of two times in the event the HR entity says they did not receive it. After two attempts, it is the patient/requestor s responsibility to come to the Center to pick up the paperwork and submit it to the HR entity. Please note failure to submit a FMLA Physician Statement request with at least 30 days notice prior to projected surgery month, to Mekhael, may cause your FMLA Physician Statement completion and applicable medical records to be delayed and/or submitted late to the HR entity. The Center, its surgeons and staff are not responsible for employer denials. 6

7 NICOTINE CESSATION CONTRACT Initial one of the following that applies to you: I currently do not use any form of nicotine, including the use of cigarettes, vapor cigarettes (e-cigarettes), cigars, or pipes. OR I currently use a specific form of nicotine (please circle all that apply) cigarettes, vapor cigarettes, cigars, or pipes. The date listed below is the date that I certify I will discontinue the use of any form of nicotine: Date I understand that nicotine use after weight loss surgery can increase the potential for developing life-threatening complications. My signature on this document certifies that I have been informed that I must not use any form of nicotine, including e-cigarettes, within two (2) months of surgery. I understand that if my pre-op nicotine testing is positive for any nicotine, my surgery will be cancelled. I can be put back on the surgery schedule in a minimum of 2-3 months, slots permitting. My signature also certifies that I will not begin using nicotine or nicotine-like products (including e-cigarettes) at any time after my surgery. Patient Signature Today s Date Witness 7