Patient Information Form

Your Contact Information

INSURANCE INFORMATION OF POLICY HOLDER

HEALTH

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AUTHORIZATION

I understand, agree and authorize the transmission of my personal and medical information as collected above to the databases of Houston Obesity Surgery (Texas) and the offices of Dr. Younan Nowzaradan. Furthermore, I understand, agree and authorize Houston Obesity Surgery to contact my insurance carrier and I authorize the disclosure of my insurance benefit coverage to Houston Obesity Surgery and the offices of Dr. Younan Nowzaradan

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Informed Consent

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Informed Consent

There are potential risks and side effects associated with any operation, including bariatric (weight loss) surgery. You are advised to consult your own personal general practice physician prior to beginning this or any other program regarding weight reduction and its advisability for your particular circumstances and health. In addition, it is critical that you are completely transparent with Dr. Nowzaradan, his affiliates and the clinical staff regarding your goals, expectations, concerns and limitations. Before seeking surgical intervention for the treatment of morbid obesity you should have tried and failed with other more conservative methods of weight loss management; ones that include a combination of diet, exercise and behavior modification.