New Dimensions Weight Loss Surgery
 
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Patient Forms

During the evaluation process, New Dimensions will require a lot of information about you and your medical history.  You should receive the key forms at the time you attend the Informational Seminar.  If you don’t have the forms, then in preparation for your initial surgeon evaluation, please print these forms and fill them out completely.

Contact and Insurance Information

→ Form that details how to contact the patient and his or her health insurance company.

Medical Information Questionnaire

→ Form that details your extensive medical and dietary history.

Authorization for Release of Medical Information

→ Form that gives our staff permission to communicate with other medical offices about your case, and to obtain medical data about you in preparation for your surgery.

Gastric bypass consent form
Gastric banding consent form
Gastric sleeve consent form
Revision surgery consent form

You will need Adobe Acrobat Reader to open above forms. Click here for a free Adobe download.

Am I A Candidate?
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About Surgery
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Planning For Surgery
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Life and Success After Surgery
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New Dimensions Weight Loss Surgery / Huebner Medical Center / 9150 Huebner Road, #250 / San Antonio, TX 78240 / Directions
210.614.9210 Phone / 866.614.3370 Toll Free / 210.614.4804 Fax / Contact Us / Links
Michael V. Seger, MD, F.A.C.S. John Pilcher, Jr., MD, F.A.C.S. Frank “Terive” Duperier, MD, F.A.C.S. Dana L. Reiss, MD, F.A.C.S. Lloyd H. Stegemann, MD, F.A.C.S.