Bariatric Surgery Online Course Confirmation Form

First Name

Last Name

Date of Birth

Email

Phone

Patient Address

City

State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

I certify that I am 18 years of age or older

Choose your preferred surgical location: Ochsner Medical Center - New OrleansOchsner Medical Center - Baton RougeOchsner Medical Center - North Shore (Slidell)

Enter the confirmation code from the online course

I have viewed the online Bariatric Surgery presentation.
• I understand that obesity is a disease.
• I understand that obesity surgery is a tool to help me lose weight.
• I understand that I will need to make lifestyle changes and maintain these changes in order to be successful.
• I understand that success means resolution and/or improvement of co-morbid medical diseases and/or weight loss.
• I understand that I will not be a candidate for bariatric surgery if I am using any tobacco/nicotine containing products, have active addiction, or I am presently using illicit drugs.
• I understand that there are risks involved with bariatric surgery including but not limited to: internal bleeding, infection, pulmonary embolus (blood clots), and stomach stricture or band slip, vitamin and/or mineral deficiencies.
• I understand that I will need to commit to multiple appointments before surgery to be evaluated, and that I will commit to keeping regular follow up visits with my bariatric team indefinitely after surgery.

Check Here for Verification of Bariatric Seminar

Insurance Information

The online seminar is completely free of charge for the patient.
However, to expedite the check-in process, and to help verify that you have necessary benefits for Bariatric Surgery (or assist with the development of financial arrangements if not), please enter your insurance coverage information from the front of your insurance card in the below fields, or select Self-Pay/No coverage if you do not have insurance.
Please note, some insurance cards display information differently, and not every card will have all the fields below:

Insurance of Self Pay? Insurance - Fill out fields belowSelf Pay/No Insurance - Skip fields below

Insurance Company Name

Type of Coverage/Coverage Plan (i.e. PPO,HMO)

Group Name

Subscriber Name

Member Name (Patient's Name)

Member Id / Policy #

Plan Effective Date

Card Issuance Date (sometimes on the back of card)