Bariatric Surgery Consent Form

Patient Information

Full Name Date of Birth Contact Number

Procedure Information

Type of Procedure Explanation of the procedure, benefits, risks, and alternatives

Consent

I acknowledge that I have read and understood the information about bariatric surgery, including risks and alternatives. Signature of Patient Date

Physician Declaration

I have explained the details, risks, benefits, and alternatives of bariatric surgery to the patient. Physician Name Signature of Physician Date