Bariatric New Patient Questionnaire
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Our mission is to greatly improve the quality of our patients’ lives by empowering patients through extensive cutting edge nutrition education and providing unique tools necessary for long term weight loss success and the reduction of medical co-morbid conditions. Our primary goal as nutrition experts is to build long term relationships with patients by educating, encouraging, supporting, and leading patients through the journey of permanent lifestyle change.

Our client expects to be treated with the utmost care and concern for their well-being and provided with a detailed and thorough education with access to long term follow up care.  We look forward to assisting and advising you throughout the process of having surgical weight loss.  The nutritional and lifestyle changes you will be making are of the utmost importance to your success with the procedure. We want to provide comprehensive nutrition education to ensure your success. We look forward to sharing our expertise and knowledge with you.
GIBNC does not participate with insurance companies, including Medicare.  Payment is due, from the patient, in full, at the time of service.  We reserve the right to refuse service if payment is not made at the time of service.  Please see our attached “Financial Policy” for details on fees.  Please read the paperwork attached prior to this appointment, and complete the attached questionnaire and forms.  By signing you are agreeing to enter into a consultation agreement with The GI and Bariatric Nutrition Center and understand your financial responsibilities to GIBNC.

Sincerely,

Nancy Lum, RD, LDN, President/Owner
Phone: 443-490-1240
SMS/ Administrative Staff: 240-452-0422
Fax: 443-490-5060

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Language Notification/ Notificación de idioma. *
(English) The GI and Bariatric Nutrition Center (GIBNC) and it's affiliates does not discriminate on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity or expression). GIBNC and its affiliates are private practices not funded by the Department of Health and Human Services (HHS). If English is not your primary language and you have difficulty communicating effectively in English, you may need to hire, at your own expense, an interpreter or document translation in order to have meaningful access to our programs. This includes, but is not limited to, verbal and written communication with our staff (including dietitians), documents and materials, and online and video education instruction. (Español )
El Centro de Nutrición Bariatrica y GastroIntestinal (GIBNC) y sus afiliados no discrimina por motivos de raza, color, nacionalidad de origen, edad, discapacidad, o sexo (incluidos el embarazo, la orientación sexual, o la indentidad/ expresion de genero). GIBNC y sus afiliados, pertenecen a prácticas privadas que no están financiadas por el Departamento de Salud y Servicios Humanos (HHS). En caso de que el Inglés no sea su lengua nativa o su primer idioma, y tenga dificultad comunicándose efectivamente en Inglés, usted tiene la opción de contratar a un intérprete o traductor de documentos por su propia cuenta y costo, para poder tener acceso y sacar provecho al máximo de nuestro programa. Esto incluye, pero no está limitado, a comunicación verbal y por escrito con nuestros empleados (incluyendo las dietistas/nutricionistas), documentos y materiales, y las clases y videos de instrucción por la internet.

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