Gastric Band Institute - Chattanooga, Tennessee - The LAPBAND® Procedure

Online Patient form

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Patient Information
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Patient Insurance Information

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Secondary Insurance Information
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Clinical Information
Patient BMI (Get it here)

Patient Diagnosis Primary		278.01 Morbid Obesity Other (if other, then please fill below)

Additional Dianosis (check all that apply)		783.49 Overeating 401 Essential Hypertension 530.81 Reflux 784.49 Hoarseness 786.2 Chronic Cough 787.1 Heartburn 327.23-29 Sleep Apnea 462 Sore Throat 786.07 Wheezing 787.03 Regurgitation 787.3 Belching Previous Weight Loss Regimens (please describe) Additional Comments

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