Video Questions

Fields marked with an * are required After completing the online video seminar about bariatric surgery, please complete the form and quiz below. You'll then be ready to attend your first appointment and take the next step toward weight loss surgery with John L. Matthews M.D.

*

By selecting this box, I certify that I have watched the entire Surgeon's Group online video seminar.
In addition, I certify that I will bring in a completed new patient packet to my first appointment.

Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth*

Email*

Phone*

Alternate Phone

Primary Insurance*

Secondary Insurance

Primary Care Physician

How did you hear about our program?*

Cancer is linked to obesity?*

True
False

Patients typically lose the most weight within the first ________ years after surgery.*

Bariatric surgery can increase your lifespan.*

True
False

What are the 3 types of bariatric surgery that we have discussed?*

In the gastric sleeve procedure is the larger portion of the stomach removed?*

Yes
No

In the gastric bypass procedure is the larger portion of the stomach removed?*

Yes
No

In order for insurance to pay for your bariatric surgery your BMI must be Between 35-40.*

True
False

Three co-morbidities that maybe required by insurance are hypertension, diabetes, sleep apnea.*

True
False

Check ALL that apply:

Things to AVOID after bariatric surgery:*

Things to DO after bariatric surgery*

Take a multivitamin with calcium and B12
Keep all follow up appointments
Drink and eat at the same time
Eat a lot of carbs

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Weight Loss Seminars Video Questions

Contact Information

Check ALL that apply: