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The Center for Minimally Invasive and Bariatric Surgery at Crozer-Chester Medical Center
Seminar Pre-Registration Form
To attend one of our free seminars about weight-loss surgery, complete the online secure seminar request form below. You will receive an email confirmation.
The two-hour seminar will provide you with an overview of weight-loss surgery, who is appropriate for weight-loss surgery, how our program works, what procedures are performed at the Crozer-Chester Medical Center, and what processes are involved when considering weight loss surgery.
Please fill out the following as completely as possible:
Fields marked with an * are required.
Seminar Information
Today's date: 11/21/09
Plans to attend seminar at*:

On seminar date*:
Patient Information
First name*:
Last name*:
Address line 1:
Address line 2:
City:
State:
Zip code:
Best phone number to contact you:
Home phone number:
Work phone number:
Cell phone number:
Other phone number:
Email address*:
Have you ever been treated by a physician for attempted weight loss?:
If so, who/when?:
How did you hear about this program?:
Insurance Information
Insurance company*:
Is this an HMO?:
Is this a PPO?:
Have you verified if weight loss surgery is a covered benefit under your plan?:
Body Mass Index Calculation
Gender*:
Age*: Years
Height*: Feet Inches
Weight*: Pounds
BMI*:
Primary Care Physician (PCP)
Name:
Phone Number:
How many years have you been seeing this PCP?:
Have you discussed non-surgical weight loss with your PCP?:
Have you discussed surgical weight-loss with your PCP?:
Would your PCP refer you to Dr. Katz for evaluation?:
Are You Taking Any Medications For
High blood pressure?:
Diabetes?:
Have you ever been diagnosed with sleep apnea?:
Do you smoke?:
Have you ever had major abdominal surgery?:
Any other significant health problems?:
If so, please explain:
An acknowledgement will be sent to your email address upon submission of your completed form.
Once you have attended the seminar, you can make an appointment with Leon Katz, M.D., our surgeon and medical director, to discuss your specific needs or concerns.