Weight Loss Surgery New Patient Application 1 Current Page 1 2 Page 2 3 Page 3 4 Page 4 5 Page 5 6 Page 6 Thank for your interest in the Duke Weight Loss Surgery program. Please complete this application to start the process. You will need your health insurance information and your primary care provider’s phone number to complete the form. All the information you provide on this secure site will be kept confidential, and will only be used by Duke Health to support your application. Visit our weight loss surgery webpages to learn about our program, our weight loss surgeons, and if you're eligible for weight loss surgery. First name Last name Date of Birth Have you ever been a patient in the Duke system?* Yes No What is your Duke Medical Record Number (MRN)? Leave blank if you do not know. Are you interested in bariatric surgery or medical (non-surgical) weight loss options?* Bariatric Surgery Only Medical Weight Loss Only Either/Both --whatever is best for me Have you previously had either bariatric surgery or a Nissen Fundoplication (a common treatment for GERD/reflux)?* Yes No Are you seeking another bariatric procedure? Yes No Was your previous surgery at Duke? Yes No Are you currently experiencing a complication of your bariatric surgery or Nissen Fundiplication? Yes No Which surgeon would you prefer? Dr. Portenier1 Dr. Sudan Dr. Yoo Dr. Seymour1 Dr. Greenberg Dr. Jain-Spangler2 First available Appointments are available in Durham for all surgeons. 1Appointments also available in Raleigh. 2Appointments also available in Burlington. Which office location would you prefer?* Burlington Durham Raleigh No Preference How did you hear about us?* Referred by a physician Friend or family member TV/Radio ad Internet ad Online search (Google, for example) Weight loss website or blog Other