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Bariatric Weight Loss Center Forms

  • Overview
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  • Overview
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Below is a list of forms to fill out for our records:

  • Patient Information
  • Financial Policy Form
  • New Patient Questionnaire
  • Current Medication List
  • Welcome Letter
  • HIPPA Document
  • The Bariatric & Metabolic Weight Loss Center Contract
  • Consent for Telehealth Consultations
  • Binge Eating Disorder Questionnaire
  • Night Eating Syndrome (NES) Questionnaire
  • Depression Screening Questionnaire

Submit Your Documents below:

  • Patient Information
  • Welcome Letter
  • Financial Policy Form
  • New Patient Questionnaire
  • Current Medication List
  • The Bariatric & Metabolic Weight Loss Center Contract
  • HIPPA Document
  • Consent for Telehealth Consultations
  • Binge Eating Disorder Questionnaire
  • Night Eating Syndrome (NES) Questionnaire
  • Depression Screening Questionnaire

Request your Medical Records:

Phone: 540-900-2322.
Email: [email protected]
There is no fee to send records to a physician.
Fees for us to send personal records: $6.50 fee for chart w/ electronic delivery. $6.50 + shipping for chart w/ paper delivery. Requests will be completed within 10 days of receipt of the request.
If you would like to download/print the form to fill out, RRS Medical Record Request Form.
Request your Medical Records

See our other Patient Resources

Accepted Insurance
Learn about the accepted insurance policies.
Accepted Insurance Policies
Common FAQ's
Learn about our common FAQ Questions
Common FAQ Questions

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