MGB
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The Mini-Gastric Bypass

        
MGB Patient
  "Buck Rogers"

More Effective than the LapBand* / Safer than the RNY Gastric Bypass**

       

West: Las Vegas, Nevada  Dr. Rutledge
Email: DrR@clos.net or Call Dr. Rutledge Now at: 702-215-9550

East: Orlando, Florida  Dr. Peraglie

Email: DrP@clos.net or Call Dr. Peraglie Now at: 407-922-3424

        
 

Family Letter Form
Please fill in the information on this form to allow Dr. Rutledge to begin your evaluation for the Mini-Gastric Bypass. Send it to Dr. Rutledge by clicking the send button at the bottom of this form. Click Here for Tips, Help and Advice on Filling out this Form.   * Please, use good Grammar and Punctuation (DO NOT USE ALL CAPS.)  * Please, Take your time, fill in the form VERY carefully. * Please, use full and complete sentences. * Please, spell carefully and use correct capitalization. * Please, Don't be sloppy. Do not rush.
Patient Identification Information:
Social Security #
Ms, Mrs., Mr., Dr.
First Name
Last Name
Address
Your Relation to the Patient
Family Member's Social Security #
Ms, Mrs., Mr., Dr.
Family Member's First Name
Last Name
Address
City
State
Zip Code
Home Phone
Work Phone
Email Address (Required, Only One)
Birth Date
Who are you? (Please give a description of your present situation and your background)
Have you ever been involved in a law suit?

Please give a brief, 4-5 sentence description of each  lawsuit(s)

 Yes
Do you understand Obesity and Morbid Obesity?

Please give a  description of Obesity and Morbid Obesity

 Yes
Do you understand the Risks of Obesity and Morbid Obesity?

Please give a  description of Obesity and Morbid Obesity

 Yes
Does Obesity affect your life?

Please give a  description of how obesity affects your life.

 Yes
Do you understand Why the Operation is performed?

Please give a description of Why the Operation is performed

 Yes
Do you understand the present controversy in Bariatric Surgery?

Please give a  description of the controversy in Bariatric Surgery

 Yes
Do you understand How the Operation is performed?

Please give a  description of How the Operation is performed

 Yes
Do you understand the Alternatives to Surgery?

Please give a  description of the Alternatives to Surgery

 Yes
Do you understand the Hoped for Benefits of Surgery?

Please give a  description of the Hoped for Benefits of Surgery

 Yes
Do you understand the Risks of Surgery?

Please give a  description of the Risks of Surgery

 Yes
Do you understand the Risks of Gastritis, Ulcers and Bile Reflux?

Please give a  description of the Risks of Gastritis, Ulcers and Bile Reflux

 Yes
Do you understand what to take for Pain and Colds?

Please give a  description of what to take for Pain and Colds

 Yes
Do you understand the Post Operative Diet Changes?

Please give a  description of the Post Operative Diet Changes

 Yes
Do you understand the Risks of Alcohol, Acetaminophen and Liver Disease?

Please give a  description of the Risks of Alcohol, Acetaminophen and Liver Disease

 Yes
Do you understand the Possible Depression After Operation?

Please give a  description of the Possible Depression After Operation

 Yes
Do you understand When to Use the Estrogen Patch in Women?

Please give a  description of When to Use the Estrogen Patch in Women

 Yes
Do you understand H. Pylori, the Billroth II, Bile Reflux  and the risks of stomach ulcers, gastritis and stomach Cancer?

Describe H. Pylori, the Billroth II, Bile Reflux  and the risks of stomach ulcers, gastritis and stomach Cancer

 Yes
Do you understand the Need for Long Term Follow Up?

Please give a  description of the Need for Long Term Follow Up

 Yes
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  Doctor's Address, Telephone and Fax #'s 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 with controversy. It is very important to take a careful and deliberate approach to considering surgery for the treatment of obesity.  

Disclaimer Notice:-Information on this web site is provided for informational purposes only.
-It is imperative that you consult your own physician regarding the applicability of any opinions or recommendations with respect to your symptoms or medical condition.
-Contact with this web site or Dr. Rutledge over the web site does not constitute a doctor patient relationship and for good quality medical care you must obtain advice and consultation form your own local physician.
-This site is intended as a resource for references on the treatment of obesity for health care professionals and educated consumers.
-The authors and editors have used sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.
-Medical knowledge changes rapidly. In view of the possibility of human error or changes in medical science, neither the authors nor the editors nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information.
This information is not medical advice or diagnosis, nor is it to be construed as medical advice, medical information, medical diagnosis, or medical prescription for curing, removing, or preventing any disease, or related symptoms. You must seek the direct assistance, advice and evaluation of your own personal physician before acting on any information found herein. These statements have not been evaluated by the Food and Drug Administration.
-Readers are Strongly encouraged to discuss and confirm the information contained herein with your own physician.
Copyright © 1998 The Center for Laparoscopic Obesity Surgery