Confidential Inquiry

Get your questions answered:
*First Name:

*Last Name:

*Age:

*Phone Number:
( ) -
*Street Address:

*City

*State    *Zip Code:
       
*email:

Gender:

Height:
Feet Inches
Weight:
lbs
BMI:

Message:

Dear Patient,
Thank you for your interest in Sacramento Advanced Laparoscopic Surgery Associates (SALSA).

THE FIRST STEP

What you should do FIRST :

The following must be completed and received by our office (by fax, mail, or in person) prior to being scheduled for your first appointment:

If you would like to download Acrobat® Reader to view PDF documents please click here

  1. PATIENT REGISTRATION Forms
    1. Please read the Patient Policies that are included in the Patient Registration Forms that you have already downloaded from the above link and printed.
  2. BARIATRIC EVALUATION FORMS - Answering All The Questions
    1. You must answer all of the questions in this form.
      If the question does not pertain to you, simply write "N/A" (not applicable).
    2. Weight Loss Surgery depends on how much detail you provide. If needed, use extra paper to describe your symptoms, weight loss attempts and medical history.
  3. NEW PATIENT GUIDEBOOK
    1. The enclosed New Patient Guidebook also tells you step-by-step how to maneuver through the pre-operative process efficiently. By following these steps, you will help speed up your evaluation and approvals for the Medical, Bariatric, Psychological, and Nutritional portions of your preparation for surgery.
  4. WE ALSO NEED A COPY OF YOUR HEALTH INSURANCE CARD (front and back)
    1. INSURANCE AUTHORIZATION FOR HMO PATIENTS -If you are an HMO patient, we will need to receive a copy of the AUTHORIZATION for your consultation.
    2. Our office staff will help in obtaining authorization but we must receive a referral form from your primary care provider (either FAX or mail).

In order to facilitate your paperwork processing, please send your completed forms and copies by mail to our address :

Sacramento Advanced Laparoscopic Surgery Associates (SALSA)
Donald J Waldrep, MD, FACS, FASMBS

Two Medical Plaza
Suite 264
Roseville, CA
95661

Phone: (916) 797-7555

Congratulations on taking your first step on your journey towards weight loss surgery. We look forward to meeting with you soon!

Sincerely,
Donald J Waldrep, MD, FACS, FASMBS

...and the staff at Sacramento Advanced Laparoscopic Surgery Associates (SALSA).

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