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Section 3 - Bariatric Surgery Agreement

 

Please complete the following Bariatric Surgery Agreement to complete section 3.

 

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Here at Iowa Weight Loss Specialists (IWLS) we are committed to your care, safety and health before and after your sleeve gastrectomy. Weight loss surgery can be a helpful tool to improve your health over the long-term. The guidelines below are an agreement between you and our providers to outline expectations for participation in our program.


Each patient is required to complete our free online weight loss surgery class. I have watched the class to completion.

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Each insurance provider and/or the program require a series of diet visits prior to my surgery. These can be performed by my primary care provider or IWLS provider. At least 2 of these required visits must be completed by an IWLS provider. Specific documentation is required for diet visits performed by a provider outside IWLS for which a documentation guide will be provided.

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Pre-operative diet visits are an opportunity to demonstrate lifestyle and behavior changes that are necessary to be successful over the long term. If I am not adherent to mutually set goals agreed upon by myself and my provider pre-operative diet visits may be prolonged or result in dismissal from the surgery program.

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Mental health clearance is a requirement for surgery. I will be evaluated by a licensed mental health provider. I have been honest in disclosing my mental health and substance use history. Certain mental health diagnoses or circumstances may disqualify me from surgery.

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I understand that surgery involves not only lifestyle change, but a commitment to taking recommended daily vitamin supplementation and at least annual lab monitoring for life. The cost of the labs and vitamins are my responsibility.

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I understand that I should avoid becoming pregnant within 1 year of surgery.

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By signing this form I acknowledge these guidelines have been explained and I understand how they could affect my eligibility for surgery.

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 Print your name.
Draw your signature.
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This section is for hospital administrators, patients can skip to the bottom to submit the form and complete section 3.

Witness Signature:

 


Date:

 


 

Continue to section 4

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