New Patient Information

Please complete the survey below. Upon completion, you will be redirected to our website at dukewls.org. Our staff will contact you within three weeks of receiving your information.

When finished, please be sure to click "submit" at the bottom of the page.

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M-D-Y

Yes

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Yes

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Yes

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Gastric Bypass (Roux-en-Y)

Lap Band (or other gastric banding)

Sleeve Gastrectomy

Duodenal Switch

Vertical Banded Gastroplasty (VBG)

Nissen fundoplication

Other

Yes

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Yes

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Please call 919-684-4064 to schedule an appointment. Please inform the scheduler that our office is requesting a long-term postop group appointment. At this appointment you will have the opportunity to request a one-on-one evaluation with a provider.

If your surgery was performed recently here at Duke, you may call the nurse triage number that was provided to you.

female

male

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referred by a physician

from a friend/word of mouth

TV/Radio

internet

African-American

Asian

Caucasian

Hispanic

Native American

Other/Not reported

Gastric Bypass (Roux-en-Y)

Sleeve Gastrectomy

Duodenal Switch (biliary pancreatic diversion with duodenal switch)

Lap-Band (adjustable gastric banding)

SIPS

Undecided/Other

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Dr. Portenier

Dr. Sudan

Dr. Yoo

Dr. Seymour

Dr. Guerron

Dr. Jain-Spangler

First available

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Duke Regional Hospital (Durham)

Duke Raleigh Hospital

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BCBS NC/SEHP

Blue Cross Federal/Out of State

Medicare

Medicaid

UHC

Cigna

Aetna

Duke Employee

Other

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Do you have Medicare? If you have Medicare in addition to Medicaid, please indicate in the question above your primary insurance as Medicare.

For patients who are Medicaid only, please be aware that bariatric surgery is not a covered benefit (either in NC or out of state).

After much consideration, the Duke Center for Metabolic and Weight Loss Surgery will not be accepting Medicaid as an approved insurance provider for bariatric surgery at this time. Unfortunately we are unable to process your application due to your insurance provider.

BCBS NC/SEHP

Blue Cross Federal/Out of State

Medicare

Medicaid

UHC

Cigna

Aetna

Duke Employee

Other

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Your BMI is below 35.0 and could be a factor in your insurance provider denying coverage for bariatric surgery. Should you wish to proceed we would encourage you to complete this application and click "submit" at the bottom of the page when finished.

Hi ______, your BMI is below the level of 35.0 that insurance companies require for bariatric surgery. Given the height and weight provided, your application will not be considered for weight loss surgery. Please consider www.dukedietandfitness.org for other options.

Blood clots in the legs

Blood clots in the lungs

Stroke/CVA

Cancer

Heart attack (Myocardial infarction)

Heart surgery

Hernia repair

Gall bladder or appendix surgery

Colon or small bowel surgery

Transplant (any kind)

Other major organ surgery (pancreas, liver, kidneys, etc)

Yes

Yes

Yes

Yes

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Chest Pain (Angina)

Irregular/Fast Heart Beat (Arrhythmia)

High Blood Pressure (Hypertension)

Reflux Disease/Symptoms (Heartburn)

Stomach Ulcers requiring meds

Anxiety

Nervousness

Depression

Hallucinations

Suicide Attempts

Homocidal Ideations

Have you ever been in counseling?

Psychological Hospitalizations

Latex Allergy

Diabetes requiring medication

CPAP/BiPAP for sleep apnea

Yes

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Never

Slight Chance

Moderate Chance

High Chance

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Required format:

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/^Pro\d{8}$/

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