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OBESITY SURGERY CENTER - Dr. Osvaldo C. Añez M.D., F.A.C.S
 
 
 

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
 

OBESITY HELP
TESTIMONIALS

 

FREE INFORMATIONAL SEMINARS

FAIR OAKS MEDICAL PLAZA AUDITORIUM

Every 3rd Saturday 10-12am

 To Register Call:
 703-956-6743

Requested Information from Seminar 


 

For Spanish presentation click below


Click here to see this presentation

 
 
   
 
OSVALDO ANEZ MD., F.A.C.S.
GENERAL, LAPAROSCOPIC AND OBESITY SURGERY
DIPLOMATE OF THE AMERICAN BOARD OF SURGERY
462 HERNDON PARKWAY SUITE 101, HERNDON VA 20170
TELEPHONE 703-956-6743
FAX 703-956-6749
 

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