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Welcome to the UT Health Tyler Bariatric Center!Please review the enclosed informationand complete all the forms to the bestof your knowledge.Instructions For Your First VisitScheduled for:1. To save time, please print and complete these formsprior to your arrival. If you are unable to complete theforms before arriving, please arrive 30 minutes early toHugh P. Babineau, MD,FACS, FASMBSyour scheduled appointment. The visit will include anindividual one-on-one consultation with Dr. Babineau orDr. Keith. You will also meet with one of our bariatriccoordinators to help the process move forward. Weencourage you to bring your spouse or another supportperson with you. Please do not bring babies or youngchildren.2. Complete and sign the enclosed forms to the best ofyour ability.3. Contact your insurance company to see if they havebenefits for “Laparoscopic Sleeve Gastrectomy,” CPTcode 433775, or “Laparoscopic Gastric Bypass,” CPTcode 43644. Ask what they require to approve surgeryCharles J. Keith, Jr., MDand begin gathering any supporting documents andrecords needed. This will speed the insurance approvalprocess.4. Bring your insurance card and completed forms andrecords to your appointment. We look forward tomeeting you!TylerBariatric Center1100 East Lake St., Ste. 150Tyler, TX 75701UT Health Tyler is accredited by the American Collegeof Surgeons (ACS)and the American Society for Metabolic and BariatricSurgery (ASMBS) as a Comprehensive Center – thehighest level attainable. The facility also is accreditedfor pediatric and adolescent bariatric surgery.
Map and DirectionsUT Health Tyler Bariatric Center1100 East Lake St., Ste. 150, Tyler, TX 75701Our office is located at East Lake Medical Plaza,at the corner of Lake St. and Fleishel Ave. in Tyler.If you’re coming from the north/west:FRONT STTake I-20 to Exit 556 for US69 Lindale/HOUSTON STTyler. Go south on US69. Continue on US69DAWSON STSouth across Loop 323 where it changes toCANCERINSTITUTEE. Gentry Pkwy. Turn right onto N. BeckhamTRAUMACLINICAve./US271 S/TX155. Continue to follow N.PAVILIONIDEL STHRBeckham Ave./TX-155. Turn left onto E. LakeSt., just past Hospital Drive. Go through theFOUNDN DRIOATDOCTORSPARKINGDRRSODODGE STFREEPATIENTPARKINGOLYMPICPLAZATOWERlight for E. Lake St. and Fleishel and ourDOCTCLINIC DRALICEASTMEDGARAGEOLYMPICGARAGELAKE STREHABILITATIONCENTERIf you’re coming from the south:DRER ANDOUTPATIENTPROCEDURESbuilding is on your left.FIRST STSECOND STEAST LAKEMEDICALPLAZAGo north on US69 to Tyler. Turn right at Loop323. Turn left on Troup Hwy/TX110. Stay onthis road (the name will change to BeckhamAve.) until you reach the light for E. LakeSt. Turn right onto E. Lake St. Go throughthe light for E. Lake St. and Fleishel and ourFIFTH STREETMEDICAL PLAZAFIFTH STbuilding is on your left.
Medical HistoryUT Health Tyler Bariatric Center1100 East Lake St., Ste. 150, Tyler, TX 75701Name:Who is your primary physician?How were you referred to UT Health Tyler Bariatric Center?Obesity HistoryHow long have you been overweight?What is the most you have ever weighed?Please list any diets, medications or other weight loss attempts. Please give dates, if you can.Medical and Surgical HistoryDo you have GERD (acid reflux)? Yes NoHow often do you have GERD symptoms?List any medications you take for GERD.Have you had gallstones or gallbladder problems? Don’t know Yes NoIf yes, describe.Have you had any liver disease or problems? Yes NoIf yes, describe.Do you have back pain? Yes NoIf yes, give details.Do you have fibromyalgia? Yes No
Have you been diagnosed with arthritis in any joints? Yes NoHave you had any joints replaced? Yes NoDo you have joint pains that have not been diagnosed as arthritis? Yes NoPlease give details on joint pains and arthritis.Do you have polycystic ovarian syndrome (PCOS)? Don’t know Yes NoDo you have any other menstrual problems, such as heavy bleeding? . Yes NoIf yes, describe.Do you have depression? Yes NoIf yes, how is it treated?Have you ever been hospitalized for depression? Yes NoHave you been diagnosed with any other mental health conditions, such as bipolar disorder, panic disorder,generalized anxiety, psychosis or personality disorder? Yes NoIf yes, please describe.Do you smoke or use smokeless tobacco? Yes NoIf yes, describe (packs per day, etc.).Do you drink alcohol? Yes NoIf yes, describe how much and how often?Do you use any “recreational” or illegal drugs? Yes NoDo you have any urinary incontinence (leakage of urine)? Yes NoIf yes, how often?Do you have pseudotumor cerebri? Don’t know Yes NoDo you have a hiatal hernia? Don’t know Yes NoDo you have an abdominal hernia or problems with your abdominal skin? Yes NoIf yes, describe.Check any others that apply and include the date of onset and any other comments: Infertility Kidney problems
Stroke Cancer Epilepsy/seizuresList all surgeries:Please list any other hospitalizations, diseases, conditions:List all medications, including over-the-counter (or attach list):List all vitamins and supplements:List any allergies, including what the reaction was (rash, itching, etc.).
Are you under the care of a psychiatrist or other mental health provider? Yes NoName of mental health provider?Have you had any problems with anesthesia? Yes NoIf yes, describe.Do you have a history of excessive bleeding? Yes NoIf yes, describe.What is your occupation?If employed, part-time or full?What is your marital status?Review of SymptomsIf you are experiencing any of the following symptoms, please mark them below. Fevers or chills Bleeding tendency Leakage of urine Chest pain Frequent headaches Depression Bloody bowel movements Excessive fatigue Skin problems Constipation Difficulty breathing Vision problems Painful urination Diarrhea Anxiety Bone pain Acid refluxWhich surgery are you seeking at this time? Laparoscopic Gastric Bypass No preference Laparoscopic Sleeve Gastrectomy Not sure Laparoscopic Adjustable Gastric Band (Lap Band) Other:Verification - Please sign and dateThe information I have provided above is accurate and complete to the best of my knowledge.Name:Signed:Date:
If you have questions about your healthcare, please call your providers office and our staff will notify your providercare: and we will return your call within 24 working hours.request routine refills 72 hours in advance of needing the medicine. Simply call your pharmacy and ask themto fax a refill request. We’ll take care of the rest. Your pharmacy should be able to process and provide yourrefill with no problem (Due to narcotics control regulations, pain medications and all controlled substancesmay only be refilled during regular business hours.Whenever possible, if you are unable to make your appointment, please call our office and we will be glad toPrint NameDOBSignatureDate
Acknowledgment of Privacy PracticesDear Patient,You have been given a copy of our Privacy Practice policy. Please complete the statement listed below and sign thisAcknowledgment. If you have any questions regarding the information set forth in UT Health’s Notice of Privacy Practices,please do not hesitate to contact the Privacy Office at (903) 596-3388.I, , have received a copy of the UT Health Physicians’ Notice of Privacy Practices.I understand that unless I object in writing that my health information can be disclosed for any of the outlined reasons given inthe Notice of Privacy Practices.SignatureDateIf unable to give to patient, please explain:Authorization for Verbal Release of InformationAuthorization for Use or Disclosure of Information for UT Health PhysiciansI, , hereby authorize UT Health Physicians to disclose my protected healthinformation to:**This protected health information is being used or disclosed for the following purposes:Information directly related to treatment, payment and/or healthcare operations. Theinformation may include, but not be limited to, medical information, demographics, insurance,date of service, type of service, charges (reasons for denial or patient responsibility), etc.***This authorization shall be in force and effective until December 31, 2019, at which timethis authorization to use or disclose your protected health information expires. Uponexpiration you will be required to sign a new authorization sheet.I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification.Signature of Patient or Personal RepresentativeDateName of Patient Personal RepresentativeDescription of Personal Representative’s Authority:6540-503REV. 1/19
If you're coming from the north/west: Take I-20 to Exit 556 for US69 Lindale/ Tyler. Go south on US69. Continue on US69 South across Loop 323 where it changes to
