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Intake Form

As a result of our commitment to providing world class care to patients of the Bariatric and Metabolic Institute, we are interested in learning more about you. Your general health, before and after bariatric surgery is of great interest to us to improve the quality of care we give our patients at the Bariatric and Metabolic Institute. For this reason we have established a database which will house health and clinical data to allow us to conduct research. The information contained in this questionnaire may become part of your permanent patient record and therefore may be subject to your medical providers being able to view this information. By conducting research on the information in the database, we will learn more about your health status and long term impact of Bariatric Surgery. It will help us to learn how to improve the lives of people receiving care at the Cleveland Clinic. For full disclosure, please click here.

 
Indicates the Required Field
 
Patient Information
 
First Name * Middle Initial
Last Name * Title
Maiden Name Suffix
Social Security #     * DOB     *
Age Gender *
Address1 * Address2
City * State *
Postal Code * Country


*
Home Phone     * Work Phone    
Cell Phone     Email *
What is your
current height?
* Feet    * inches
What is your
current weight?
* lbs
Primary Language
 
Insurance Information
 
Primary Medical Insurance Carrier *
Insurance Carrier
Address
Address2 
City State        Zip code  
Group Number Insurance Carrier
Phone #
   
Member ID # Relationship to
Policy Holder
Policy Holder
First Name
Policy Holder
Last Name
Policy Holder DOB     Policy Holder
Phone #
   

Secondary Medical Insurance Carrier
Insurance Carrier
Address
Address 2
City State       Zip code  
Group Number Insurance Carrier
Phone #
   
Member ID # Relationship to
Policy Holder
Policy Holder
First Name
Policy Holder
Last Name
Policy Holder DOB       Policy Holder
Phone #
   

How did you hear about us? *
 
Pick your secret question *
Answer *
 
 
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Please review all your information before clicking "Submit" to ensure that it is accurate.
 
 
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