New Patient Consultation Form KIM BARIATRIC INSTITUTE Patient Information Date: Patient's Name: Patient D.O.B: Address: Patient Phone#: Alt Phone#: Email address: Reason for Consultation: (Bariatric, Gall Bladder, EDG) Diagnosis OCD-10: BMI: Referring Physician's Printed Name or Stamp: NPI Number: Fax: Referring Physician's Office Phone: Email: Coordinator Contact info: Insurance Provider: ID: Group: Based on the patients insurance we will pair them with the appropriate physician once benefits are verified. Bridget Holden, MD,FACS David Kim, MD,FACS Manuel Castro, MD Hein Le, MD All Surgeons perform General Surgery, EDG as well as our KIM Inverted Gastric Sleeve Please email this form and a copy of the following to or Fax 214-494-4354 Patients demographic/copy of ins card Most recent office note Recent history and physician report Current medication list Relevant diagnostic reports (EDG, Sleep study) Other relevant information Please call Lisa Jorge Intake Manager at 817-581-6100 x111 with any questions, special instructions or concerns. Thank you for the patient consultation.
New Patient Consultation Form KIM BARIATRIC INSTITUTE Patient Information Date: Patient's Name: Patient D.O.B: Address: Patient Phone#: Email address: Alt Phone#: Reason for Consultation: (Bariatric, Gall Bladder, EDG) Diagnosis OCD-10: BMI: Referring Physician's Printed Name or Stamp: NPI Number: Referring Physician's Office Phone: Coordinator Contact info: Fax: Email: Insurance Provider: ID: Group: Based on the patients insurance we will pair them with the appropriate physician once benefits are verified. David Kim, MD,FACS Bridget Holden, MD,FACS Manuel Castro, MD Hein Le, MD All Surgeons perform General Surgery, EDG as well as our KIM Inverted Gastric Sleeve Please email this form and a copy of the following to or Fax 214-494-4354 Patients demographic/copy of ins card Recent history and physician report Relevant diagnostic reports (EDG, Sleep study) Most recent office note Current medication list Other relevant information Please call Lisa Jorge Intake Manager at 817-581-6100 x111 with any questions, special instructions or concerns. Thank you for the patient consultation.
New-patient-consult-form1.docx