Forms

All of our forms are listed below. Please download and print the appropriate form and bring it with you to your next appointment.

  • Consent to Disclosure
    This Document states that the patient is aware and agree that any health information regarding your healthcare may be release the insurance company, employer, doctors and facilities.
  • Patients Rights and Responsibilities
    This Document informs YOU, the patient, of your HIPAA rights in the healthcare industry and the quality of healthcare that is provided to you.
  • Photographic Release
    Signed Document gives Dr. Dirk permission to advertise a patient successful weight loss journey. (before and after pictures). Patient will be contacted prior to any advertisement.
  • Procedure Confirmation
    Signed Document gives Dr. Dirk permission to advertise a patient’s successful weight loss journey (before and after pictures)
  • Patient Health History Packet
    Please answer all the questions completely as possible. All the information that is provided is essential for Dr. Dirk to fully understand any health related conditions. This may also help with insurance approval of surgery.
  • Medical Release Form
    This form is to release medical records from another Medical doctor or facility.