Ph: 806.239.3848 | Fx: 831.471.8162 rgordhamer@gmail.com

Patient Registration Form

 

  • Pre Bariatric Surgery Mental Health Evaluation

    Patient Registration

    PLEASE COMPLETE ALL SECTIONS IN ONE SITTING.

    Although some patients may finish sooner we recommend allowing at least 20-40 minutes to complete. Please follow the directions at the top of the page in each section.

    We respect your privacy and will never disclose your personal information without your written consent.

    Don’t accept any help in answering questions. The answers must be solely your own.

    If you have any questions please call us at (806) 239-3848.

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