Get Ucla Bariatric Surgery New Patient Application 2016-2026

Filling out the UCLA Bariatric Surgery New Patient Application online is an essential step in beginning your weight loss journey. This guide will provide you with clear and supportive instructions on how to accurately complete the application to ensure a smooth process.

Follow the steps to successfully complete the application.

1. Click ‘Get Form’ button to obtain the necessary form and access it for completion.
2. Begin with the personal information section. Enter your full name, date of birth, age, and contact details, including your home, work, and cell phone numbers. Choose your primary language and provide your email address.
3. Continue filling out your marital status, number of children, and whom you reside with, ensuring to provide all relevant details accurately.
4. In the primary care physician information section, fill in the complete contact information for your primary care doctor, including the doctor's name, company, address, phone number, and optionally, email address. Ensure accuracy for effective communication.
5. Enter insurance information as it appears on your insurance card. Include details like the name on the card, type of insurance, insurance company, member ID number, and any relevant contact information for providers.
6. Provide your bariatric background, including how long you have considered surgery, any research you've conducted, and how you learned about the program.
7. Move to the dieting history section. Record your dieting history by marking those you have tried, age you started dieting, approximate weight at age 18, and your experience with medically supervised programs.
8. Detail your food preferences, including frequency and types of snacks, beverages, and eating habits you have.
9. Complete the personal medical history section by marking all relevant conditions that apply to you. This includes cardiac, endocrine, pulmonary, urological, psychological, GYN history (if applicable), and other personal medical histories.
10. Fill in your prescription medications and any over-the-counter or herbal supplements you take. Be thorough, as you may need to list this on an additional page if necessary.
11. In the family and social history section, provide information about your family health history, alcohol and tobacco usage, exercise habits, and any support systems you have.
12. Acknowledge the program policy and sign or type your name to confirm your interest in pursuing bariatric surgery. Ensure you date the application.
13. After completing the application, save your changes, then print or download it. Attach a copy of the front and back of your insurance card and submit via email, fax, or mail as instructed.
14. Follow up with the office three business days after submission to confirm receipt and discuss any next steps.

Complete your application online today and take a vital step towards your health and wellness.