Consultation Request
New Patient Coordinator Tel: 617-726-0373
Fax: 617-724-6565
Email: weightcenter@partners.org
Today’s Date:
___________
Obesity Medicine Consultation
Type of
Referral
(check all
that
apply)


Comprehensive, multidisciplinary, medical evaluation.
May result in referral for Weight Loss Surgery consultation.
Weight Loss Surgery Consultation


Patient must have BMI > 35 and desire weight loss surgery.
Comprehensive evaluation involving a metabolic surgeon, a dietitian and a psychologist.
Rapid Weight Loss to Precede Medical, Surgical or Fertility Procedure



Pre-Operative Weight Reduction Program (POWR).
This is a 6-12 week program for rapid short-term weight loss.
Recommended for patients with BMI of 35 or lower (patients with BMI >35 should be referred
for obesity medicine consultation)
Patients with previous weight loss surgery with or without complications
Surgery and Complication:
Which location is your patient interested in?
Clinical
Information
(*required
information)
*Weight:
*Height:
Boston
Danvers
Either
BMI (if known):
Major weight-associated disorders (check all that apply):
Diabetes mellitus
Sleep apnea
Depression
Severe back or joint pain
Asthma or COPD
Major Mental illness
Heart disease
GERD
Anxiety disorder
Fatty liver disease
Infertility or PCOS
H/o Cancer:
Type
Other major medical problems:
If you have discussed this referral with a Weight Center provider please list provider name:
Patient
Contact
Information
Patient Full Name:
(Last, First, MI)
MGH Unit No:
Patient Date of Birth:
If no number is available, please instruct the patient to call the
MGH Registration Center at 866-211-6588.
Gender:
Male
Female
Patient Address:
Evening Phone:
City/ State/ Zip:
E-mail Address:
Patient will require an interpreter;
Referring
Provider
Daytime Phone:
Primary Language:
Name of Provider:
Phone:
Practice Name:
Fax:
Please fax this form to
617-724-6565