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Section 6 - Bariatric Surgery Agreement

 

Please complete the following Bariatric Surgery Agreement to complete section 6.

 

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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.


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Please confirm that you watched the course video and reviewed the entire PowerPoint presentation:
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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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I understand that I will be expected to pay my down payment for surgery at the time of my last diet visit. 

 

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While Iowa Weight Loss Specialists will try to make every effort to verify my insurance coverage before my first visit, I understand that it is my responsibility to also verify my coverage for bariatric surgery and confirm that Iowa Specialty Hospitals-Iowa Weight Loss Specialists is in network with my insurance company.

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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:

 


 

 

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