Welcome to the Center for Surgical and Medical Weight Loss Thank you for choosing Saint Thomas for your weight loss journey. Please take the time to read this information carefully. My appointment is scheduled, what are my next steps? 1. Check-in for your appointment on-line and complete the required, medical history questions. This includes your family history, past medical history, social history and surgical history. You will receive an automated email from Phreesia 1-2 days prior to your appointment allowing you to pre-check-in. 2. Complete the attached New Patient Form (pages 4, 5, 6) and bring to your appointment. Patients failing to arrive early enough will not have time to complete the form, and will have to be rescheduled. 3. View online seminar at: https://www.sthealth.com/medical-services/bariatrics-and-weightloss/saint-thomas-midtown/how-do-i-begin If you do not check-in on-line and/or complete the New Patient Form in advance, you must plan to arrive at least 30 minutes before your appointment time to complete these requirements prior to your appointment time. Patients failing to arrive early enough will have to be rescheduled to another day. To accommodate all of our patients as promptly as we can, patients that are more than 10 minutes late for an appointment will have to be rescheduled. Thank you for your understanding. What do I bring to my appointment? New Patient Form Completed Driver s License Insurance Card List of Medications Do I have bariatric benefits? As a courtesy, our insurance specialists will contact your insurance company to find out if you have bariatric benefits. If you have questions regarding your insurance or bariatric benefits, please call 615-284-2400 and select the appropriate option to speak with one of our insurance specialists. What should I expect at my appointment? Your first appointment will last approximately 60 minutes. 1
During the appointment, you will meet with our Nurse Practitioner/Physician Assistant for a comprehensive medical history, physical exam, review of completed forms, risks and complications, and discuss your surgical options in depth. You will also meet with our Patient Advocate who is a successful surgical weight loss patient, to learn about our interdisciplinary team, program steps, and insurance company requirements for surgery approval. If you do not have insurance benefits for weight loss surgery (bariatric), information on discounted self-pay fees and financing options will be provided to you. Disability and/or Family Medical Leave Act (FMLA) Requests Completion of paperwork requests must be given hard copy to the attention of Medical Assistant at least 30 days in advance of the Patient s projected month of surgery. Complete applicable employee sections prior to making the request. Completed paperwork is faxed by the medical assistant to HR/entity. Fax confirmations are kept by the medical assistant. The medical assistant will fax a maximum of two times to HR/entity. If HR/entity says they are still not in receipt, it is the patient s responsibility to pick up the paperwork and submit to their HR/entity. Please note failure to submit requests with at least 30 days notice prior to projected surgery month may cause a delay in the FMLA process from being completed by a deadline. The Center, its surgeons and staff are not responsible for denials. 2
Directions to the Center for Surgical and Medical Weight Loss 300 20 th Avenue North, Suite 301 20 th Avenue Medical Building, 3 rd Floor Nashville, Tennessee 37203 615-284-2400 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 RIGHT onto 20 th Avenue North (one way street) 5) On your RIGHT, there is free valet service available at the ground level entrance between the 20 th Avenue building and 20 th Avenue parking garage 6) Or, you may turn RIGHT at State Street to access the parking garage to self-park. Once you turn onto State Street, the garage will be on your LEFT. 7) Once you enter the 20 th Avenue Building, take the elevator or the stairs to the 3 rd floor. Turn RIGHT down the hallway and Suite 301 will be on your LEFT. If you are traveling on I-40 Eastbound: 1) Exit at Church Street - exit 209A 2) Turn RIGHT at the bottom of the exit ramp onto Church Street 3) Turn RIGHT onto 20 th Avenue North (one way street) 4) On your RIGHT, there is free valet service available at the ground level entrance between the 20 th Avenue building and 20 th Avenue parking garage 5) Or, you may turn RIGHT at State Street to access the parking garage to self-park. Once you turn onto State Street, the garage will be on your LEFT. 6) Once you enter the 20 th Avenue Building, take the elevator or the stairs to the 3 rd floor. Turn RIGHT down the hallway and Suite 301 will be on your LEFT. 3
New Patient Form Please note: Past Medical, Family, Social, and Surgical Histories should be completed on-line in Phreesia Check-in in advance of your appointment Patient Name: Date: Date of Birth: Age: Sex: SS#: - - Allergies: Emergency Contact: Relation: Phone: Occupation: Status (circle one): Full time/part time/retired/disabled Marital Status: Single Married Domestic Partnership Divorced Widowed 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? Name of person who will be with you on the day of surgery? Relation: May we keep that person updated regarding your care? YES NO Name of Primary Care Physician: Name of PCP Practice: PCP Office Phone: Preferred Pharmacy Name: Pharmacy Phone #: Have you ever had an ER visit and/or hospitalization for mental health/psychiatrics reasons? YES NO If yes, list date(s): Have you ever had suicidal thoughts or a suicide attempt? YES NO If yes, list date(s): 4
Patient Name: Date of Birth: Name of Cardiologist: Office Phone: Name and Location of Cardiology Practice: Name of Pulmonologist: Office Phone: Name of Practice Pulmonologist is located: Current Medications Please list ALL CURRENT medications, vitamins and minerals OR attach a complete list Medication Name Dosage Medication Name Dosage 1. 10. 2. 11. 3. 12. 4. 13. 5. 14. 6. 15. 7. 16. 8. 17. 9. 18. OFFICE USE ONLY: Height: Weight: BMI: BP: / HR: 5
NICOTINE, MARIJUANA AND ILLEGAL DRUG 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, dip, chewing tobacco or pipes, nicotine gum, or any form of marijuana or illegal drugs (ex. cocaine, heroin, meth, ecstasy, bath salts, etc.). OR I currently use a specific form of nicotine (please circle all that apply) cigarettes, vapor cigarettes, cigars, dip, chewing tobacco, pipes, or nicotine gum. I currently use a form of marijuana or illegal drugs (ex. cocaine, heroin, meth, ecstasy, bath salts, etc.). I certify I will discontinue the use of any form of nicotine, marijuana, or illegal drug use on (date):. I understand that the use of nicotine, marijuana, or illegal drugs 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), marijuana, or illegal drugs (listed above). I understand that if my pre-op nicotine testing is positive for any nicotine, my surgery will be canceled. I understand if my pre-op drug testing is positive for marijuana or illegal drugs, my surgery will be canceled. My signature also certifies that I will not begin using nicotine or nicotine-like products (including e-cigarettes) at any time after my surgery. Please note that if you engage in nicotine use 2 months prior to testing, it will show up as positive on a nicotine test. Patient Name (Print) Patient Signature Witness Today s Date 6