Please list your allergies
and tell us what happens.
Do you drink alcohol? How
much?
Are you a smoker? How much?
Do you have a family history
of obesity?
Describe the obesity history
in you family.
Are there serious medical
illnesses in your family?
Yes?
Diabetes
Heart
Disease
Stroke
High Blood
Pressure
Cancer
Describe the Medical
illnesses in your family.
Your Referring
Doctor:
Doctor's name?
Street address.
Doctor's City?
Doctor's State.
Zipcode.
Telephone #.
Doctor's Fax #
Very Important
Family
Information:
Marital status.
Spouse's name?
Other Comments:
Notes (Any other comments)
Remember: Your Insurance Company's Fax # and your Doctor's
Fax # are VERY VERY Important!
This notice describes
how information about you may be used and disclosed and how you can gain access
to this information.Please review carefully
Contact
Information:-Telephones: *** CLOS West: 702-456-4643; Trish Lanman 702-376-3446, Sandy Brubaker 702-376-3647; Jennifer Brubaker 702-376-9339, Dr. Rutledge 702-215-9550; 989-450-8081 Kim Hazen 989-450-8081 *** CLOS Florida: Flo Ballengee 863-899-3463 Wayne Robbins 704-682-1549 Elizabeth Robbins 704-928-6693 Dr. Cesare Peraglie 407-922-3424
Email Us Anytime for Help:
Email: Dr. Rutledge DrR@clos.net, *** CLOS West: Trish Lanman Trish@clos.net, Sandy Brubaker SandyB@clos.net Dr. Rutledge DrR@clos.net, Kim Hazen khazen@clos.net *** CLOS Florida: Flo Ballengee flo@clos.net, Wayne Robbins wr@clos.net Elizabeth Robbins epr@clos.net Dr. Peraglie drp@clos.net
Addresses:
Address: *** CLOS West Office: Dr Robert Rutledge / CELOS, 98 E Lake Mead Parkway Suite 302, Henderson NV 89015, Office 702-456-4643, Office fax: 702-456-1173, Contacts: Trish Lanman 702-376-3446 Trish@clos.net, Sandy Brubaker 702-376-3647 SandyB@clos.net, Jennifer Brubaker 702-376-9339 Jen@clos.net, Dr. Rutledge 702-215-9550 Drr@clos.net Kim Hazen 989-450-8081 khazen@clos.net *** CLOS Florida: 40124 Highway 27, Suite 203, Davenport, FL 33837, Wayne Robbins 704-682-1549, wr@clos.net, Elizabeth Robbins 704-928-6693 epr@clos.net, Dr. Peraglie 407-922-3424 drp@clos.net
Warning:
Gastric Bypass Surgery is a MAJOR surgical procedure. It
can be associated with significant
risks and complications, up to and including death.Weight loss surgery is a rapidly developing area of medicine.
Bariatric surgery is filled withcontroversy. It
is very important to take a careful and deliberate approach to considering
surgery for the treatment of obesity.