Lap Band Candidate Screening
Serving Western Orange and Sullivan Counties, NY,
Northern Sussex County, NJ, and Pike County, PA.

Our packet will be mailed out to you, upon receipt of this filled out questioner form.
 Thank you,
Cynthia Marsilio - Bariatric Program Director

(*) marks required fields

Insurance:
PCP:
Referral:

*First Name:

*Last Name:

*Email:

Home Phone:

Work Phone:
Best Time to Call:

Address:

City:

State:

Zip Code:

Age:
Date of Birth:
Height:
 ft in
Weight:
BMI:
Do you Smoke?:
Yes No
If yes how much?
Do you have any of the following medical conditions?

Diabetes Hypertension Anxiety Hypothyroid Sleep Apnea
Reflux/Heartburn Asthma Depression Other Bipolar Heart Problems
Other

What medications are you currently taking?

Would you like to receive future health system publications?
 Yes   No

 

 

 

 



 
© Copyright 2006, Bon Secours Charity Health System, Inc

Bon Secours Community Hospital
160 E. Main Street, Port Jervis, NY 12771
(845) 858-7000