OBESITY SURGERY CENTER INC. OSVALDO ANEZ, MD, FACS. DIPLOMATE OF THE AMERICAN BOARD OF SURGERY APPOINTMENT REQUEST FORM

NAME: DATE: AGE: RACE: HEIGHT WEIGHT BMI IDEAL WEIGHT PHONE: FAX: E-MAIL: Which of these is your preferred method of contact: Referring Physician: Phone: Fax. CO-MORBID CONDITIONS High Cholesterol Diabetes Pain in Joints/Multi Sites Acid Reflux High Triglycerides Thyroid Problems Urinary Incontinence Peptic Ulcer Disease Hypertension Gallstones Asthma Hiatal Hernia Heart Disease Breast Cancer Shortness of Breath Anemia Ankle Swelling Uterine/Cervical CA Sleep Apnea Blood Clot Depression Arthritis Snoring Other Insurance information: Name of insurance company: Type: HMO PPO Self - pay We recommend that you contact your insurance company ahead of time to ensure that bariatric surgery is a covered benefit. Scheduling preference: Which time of day is more convenient for you? Morning Afternoon How soon would you like an appointment? First available 1-2 months 2-3 months 3-6 months