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Bariatric Surgery Intake Form

Asks about current weight & height, weight history timeline, and obesity-related comorbidities. Built for MBSAQIP-accredited bariatric surgery programs.

Questions
22
Pages
3
Time
about 6 min

Includes

  • E-signature
  • Insurance card or ID upload
  • Insurance details
  • Medication list
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Your practice

Bariatric Surgery Intake Form

Page 1 of 3 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • MBSAQIP-accredited bariatric surgery programs
  • Metabolic surgery and revision bariatric surgery practices
  • Multidisciplinary weight management clinics
  • Insurance pre-authorization and medical necessity documentation

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What's inside

Page 1 · Your information

  1. Full NameText · Required
  2. Date of BirthDate
  3. Phone NumberPhone
  4. Email AddressEmail

Page 2 · Additional details

  1. Sleep Apnea & CPAP StatusLong Text
  2. Prior Weight Loss AttemptsLong Text
  3. Prior Bariatric/GI SurgeryLong Text
  4. Nutritional AssessmentLong Text

Page 3 · Additional details

  1. Psychological Evaluation StatusLong Text
  2. Support System & LifestyleLong Text
  3. Preferred Surgical ProcedureLong Text
  4. Insurance Pre-Authorization DocsFile Upload

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Bariatric Surgery Intake Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 22 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Bariatric Surgery Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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