Forms & Templates

Patient Referral Form

As a physician, you can refer a patient to our services at the St.Vincent Bariatric Center of Excellence by printing, completing, and faxing the following form to our office.

Patient Referral Form

Letter of Medical Necessity Template

The following is a letter template for physicians who are referring a patient for bariatric surgery. Please feel free to open the document and adjust the content to fit your patient and his or her conditions.

Letter of Medical Necessity Template

Supervised Weight Loss Forms


Many patients are required by their insurance carrier to complete a medically supervised weight loss program prior to surgery. Any weight that can be lost prior to surgery will aid in successful surgical outcomes.

For your convenience, we’ve included the 6 months supervised weight loss forms here:

  • Month 1
  • Month 4
  • Month 2
  • Month 5
  • Month 3
  • Month 6
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