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Get CA 15-2711-1 - Stanford 2014

Page 1 of 8 Bariatric & Metabolic Interdisciplinary Clinic Stanford Hospital and Clinics Bariatric & Metabolic Interdisciplinary (BMI) Clinic 900 Blake Wilbur Drive, W0048, MC 5355, Palo Alto, CA 94304 New Patient Coordinator: (650) 736-5800, option 1 Fax: (650) 723-8378 Patient Questionnaire This questionnaire is required. Please complete and return as soon as possible to allow us to schedule your appointment. Name: _______________________________________ DOB: _______________ Age: ___________.

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