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

Patient Registration Form

 

  • Pre Bariatric Surgery Mental Health Evaluation

    Simple as 1-2

    1. Complete Patient Registration
    2. Complete Assessment

    PLEASE COMPLETE ALL SECTIONS IN ONE SITTING.

    Although some patients may finish sooner we recommend allowing at least 45-60 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

    You will be asked to pay $100 with a credit card. This is your only expense for this mental health evaluation service.

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

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