Pre-op Nutrition Class


Step 1

Patient First Name:

Patient Last Name:

Date of Birth:

Today's Date:

 

Step 2

This patient has received bariatric nutrition counseling. The patient indicates his understanding of the following materials covered during the counseling session:(All check boxes are required)

 

I understand the nutritional (restrictive and/or malabsorptive) effects of bariatric surgical procedures.

I have been given the diet progression required for bariatric procedures. I understand the diet progression and agree to follow the dietary instructions and restrictions for my surgical procedure.

I agree to begin multi-vitamin and calcium supplementation immediately. I will adhere to any additional recommendations regarding vitamin or mineral supplementation recommended by my physician before and after surgery.

I understand that bariatric surgery requires a lifetime commitment to dietary/excercise changes and I am willing to make those changes.

I agree to keep my follow-up appointment to monitor my nutritional status.

 

Step 3

Virtually sign by typing your name below: (Required)

 

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