Bariatric Surgery Questionnaire

In order for you to submit this questionnaire electronically, you will need to provide personal information. By proceeding through this notice and providing the requested information, you consent to the disclosure of such information to Avita Health System. The information that you provide will be placed into our electronic database. Your specific information will be accessed and used only for scheduling purposes. The information that you provide will not be shared with other organizations, and cookies or other tracers will not be used to collect information or track your computer use. However, you should note that electronic mail and other internet communication channels may not be secure against interception by non-authorized individuals. If you do not wish to transmit your medical information electronically, please call the Center for Bariatric Surgery Office at 567-307-7854.


Medical Conditions
Insurance Information
Once we have reviewed your information and we have verified your insurance coverage, our office will contact you to make the necessary appointments to start your weight loss journey.