Are you easily fatigued? Or easily exhausted?
Do you have shortness of breath?*
Do you use a B-PAP or C-PAP while you sleep?
Do you consume Tobacco / Nicotine?
Do You Consume Alcohol?
Do You Use Recreational Drugs?

Medication Types (check if you take any of the following):

Do You, or have you in the past taken Blood Thinners? (If yes, Explain below)

Allergic Reactions:
Do you have allergic reactions to any of the following?

Medical Conditions:

Please check box for any of these medical conditions you have or have a history of, then fill out box below with the date of diagnosis, treatments received and other necessary information.


Medical Conditions:

Surgical History:

Have you had any previous surgeries?

Complications from Any Surgery?

Ever have any problems with Anesthesia?

Gynecologic History (women only)
Are you Pregnant or is there a Possibility of Becoming Pregnant?

Ever have a C-section?

Bleeding is:


Personal Info

Truthful Statements – Terms and Conditions

I agree the statements I’ve made above are truthful, honest, and accurate. I understand that if I lie, mislead or fail to tell the truth, there can be serious consequences including, but not limited to: my physical wellbeing and health, mortality (death), complications, poor surgical outcomes, I may incur additional fees, and may cause the surgery to be cancelled without any right to money already paid.

Honesty and Truth:

I am interested in undergoing surgery with Renew Bariatric’s doctors. I understand that Renew Bariatric is a facilitator, and is not a medical provider. I have read thoroughly, and agree to the Terms of Conditions (new window), Deposit Policy (new window) and the Privacy Policy (new window). I’ve read Renew Bariatrics’ HIPAA Notice of Privacy Practices and Communication Policy (new window), and I agree with the terms therein.

Intent and Policies:


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