Request a Consultation With Our Surgeons

Your care begins even before your first consultation with our surgeons. After you complete the form below, our muti-disciplinary team will evaluate your request and contact you to schedule your appointment. If you need assistance completing this form, you can reach us at 410.550.0409. After you have submitted your information, please allow 7 days for us to process your request.

First Name «
Last Name «
Date of Birth « MM/DD/YYYY
Consultation Type «	General Surgery Bariatric Surgery
Phone « Calls are made between 8:00 am and 4:00 pm, Monday through Friday. Please provide a number where we can reach you during that time.
Email «
Preferred Contact «	Phone Email
Would you like to join our low-volume mailing list? This monthly email lists our free support groups and other upcoming events.	[ Yes ] [ No ]
How did you hear about us?	-- Select from the following -- Radio advertisement Hopkins Bayview Website Google Other Search Engine Called the Hopkins Bayview Bariatrics Department Bayview News Baltimore Sun Primary Care Physician A friend or relative A Current Hopkins Bayview Bariatric Patient Obesityhelp.com Other
Other: If you answered "Other", please describe.
Age «	-- Select from the following -- under 18 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70+
Gender	Female Male
Height (feet) «	-- Select from the following -- 4 5 6
Height (inches) «	-- Select from the following -- 0 1 2 3 4 5 6 7 8 9 10 11
Weight (lbs) «
Street Address «
City «
State «	-- Select from the following -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas (except Canada) Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon
Zip «
Primary Care M.D. «
PCP Phone
Insurance «
Past Surgeries
I'm Interested In... Select from these options if you have not had bariatric surgery before.	Laparoscopic Gastric Bypass Open Gastric Bypass Laparoscopic Lap Band Laparoscopic Duodenal Switch Laparoscopic Sleeve Gastrectomy Not Sure
Revision of Past Procedure If you've had bariatric surgery before and need revisional surgery, please select an option. Otherwise, leave this area blank.	StomaphyX Other
We are finding that most insurance companies don't cover the StomaphyX procedure. Please verify your benefits in advance if you do not wish to pay for the procedure out of pocket.
Health Conditions «	None Asthma Back pain Blood clot in leg Blood clot to lung Congestive heart failure Depression Diabetes Gallstones GERD High blood pressure High cholesterol Joint pain Liver disease Lupus PCOS Rheumatoid arthritis Scleroderma Sleep apnea Swelling in legs Urinary incontinence Other (please list)
Other Health Conditions
I'd Like to See	Dr. Lidor Dr. Magnuson Dr. Schweitzer Dr. Steele Not Sure
Please note: only Drs. Schweitzer and Steele perform the StomaphyX procedure.
Is There Anything Else We Should Know?
** PLEASE NOTE: If your insurance company requires a referral, we CANNOT schedule your appointment until our office has received your referral. **
Fields marked with "«" are required.

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4940 Eastern Avenue. Baltimore, Maryland 21224. 410.550.0100

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May 16, 2008