Forms

Please download the necessary forms below.  You may then print them, and complete those indicated prior to your visit.  To download a form, simply click on the name of the form.  It will open in your browser.  If you prefer to save the form to your computer, you may right-click on the name of the form, then left-click on "Save Target As."

Completing this information in advance is a great way to minimize wait time in the office.

Demographics  (Please Complete and Return)

Medical Record Form   (Please Complete and Return) 

Social Security Consent  (Please Complete and Return)

Social Security Disclosure (For Review)

Privacy Policy (For Review)

Signature Page  (Please Complete and Return)

Statement of Financial Policies (Please Complete and Return) 

*$9,888 price includes facility fees at Turning Point Specialty Surgery Center, surgeon and anesthesiologist professional fees, Lapband device, one year of unlimited office visits for band adjustments.