Patient Questionnaire Form

Dear Prospective Patient:

Thank you for your interest in our Bariatric Surgery Program. We offer comprehensive pre-operative and post-operative care, provided by a multidisciplinary team of excellent compassionate professionals. We strive to maximize your success with weight loss and improvement of associated medical conditions. We offer the Lap-Band, the Laparoscopic Sleeve Gastrectomy, and the Roux-en-Y Gastric Bypass procedures. As of 2018, Tri State Bariatrics has performed over 8000 bariatric surgeries.

Thank you for scheduling an appointment at Tri State Bariatrics. Once you have scheduled an appointment we request you take time before your appointment to print off and fill out the “Patient Questionnaire” , unless you have accessed your Patient Portal and answered the questions already.

Click Here to download patient questionnaire

Patient ‘s Questionnaire

At your first appointment please bring this completed “Patient Questionnaire” with you. You will be meeting with many of our staff members at this first appointment who will use this important information.

At your first visit, several staff members will be meeting with you on a one on one basis. You will meet with our Nurse Practitioner who will complete a thorough history and physical. A Registered Dietitian will discuss in detail your previous diets and provide to you information about food choices. The Registered Nurse will explain the surgical options and provide you with written education materials. Our Insurance Liaison will affirm bariatric coverage under your insurance plan. Then you will meet with our Patient Navigator who will provide to you a step by step guideline about the pre-operative tests and consults that are needed prior to scheduling your surgery.

Office Locations:

Suffern, NY
156 Route 59, Suite A2, Suffern, NY 10901

Middletown, NY
384 Crystal Run Road, Suite 201, Middletown, NY 10941

Fishkill, NY
200 Westage Business Center, Suite 119, Fishkill, NY 12524

Sleepy Hollow, NY
777 North Broadway, Suite 207, Sleepy Hollow, NY 10510

Schedule your seminar today and print out the patient forms to get a jumpstart on the process.

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Our Locations

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384 Crystal Run Road,
Suite 201
Middletown, NY 10941

(845) 692-8780

200 Westage Business
Center Drive,Suite 119
Fishkill, NY 12524

(845) 896-0610

777 North Broadway,
Suite 204
Sleepy Hollow, NY 10591

(845) 517-2870

Airmont Professional Center
156 Route 59, Suite A2
Suffern, NY 10901

(845) 517-2870

1 Hatfield Lane
Goshen, NY 10924

(845) 517-2870

460 Gidney Avenue
Newburgh, NY 12550

(845) 692-8780