Weight Loss Surgery New Patient Application The following special characters are allowed: `!@#$%&*()-_=+;:'"”“’‘´,.?/\ Current Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Thank for your interest in the Duke Weight Loss Surgery program. If you are interested in Weight Loss Revision surgery, please call 919-470-7000, and do not proceed with filling out the application. 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?YesNo 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 OnlyMedical Weight Loss OnlyEither/Both --whatever is best for meHave you previously had either bariatric surgery or a Nissen Fundoplication (a common treatment for GERD/reflux)?YesNoAre you seeking another bariatric procedure?YesNoWas your previous surgery at Duke?YesNoAre you currently experiencing a complication of your bariatric surgery or Nissen Fundiplication?YesNoWhich surgeon would you prefer?Shaina Eckhouse, MDJacob A. Greenberg, MDKunoor Jain-Spangler, MDJames Jung, MD, PhD, FACS, FRCSCOzanan R. Meireles, MDDana D. Portenier, MDKeri A. Seymour, DORanjan Sudan, MDJin S. Yoo, MDFirst availableAppointments are available in Durham for all surgeons.Which office location would you prefer?DurhamRaleighNo PreferenceHow did you hear about us?Referred by a physicianFriend or family memberTV/Radio adInternet adOnline search (Google, for example)Weight loss website or blogOther