101 Robeson Street, Suite 200 Fayetteville, NC 28301   P: (910) 323-2696   F: (910) 323-8636

Obesity Surgery Patient Agreement


DIRECTIONS:
The following is a contract between you and Dr. Carter. Please type your name and check all boxes to show that you agree to give your full participation in the bariatric surgery process. Then click submit below to send your contract to our office.


I, , agree to fully participate in the Bariatric Surgery Program at Fayetteville Weight Loss Center, LLC. This means that I...

   Will take my vitamins/supplements as directed for the rest of my life.
   Will follow the guidelines of the gastric bypass diet.
   Will exercise on a regular basis both before and after surgery.
   Will continue to come in for follow-up appointments at 2 weeks, 4 weeks, 3 months, 6 months, 1 year and every year after that for the rest of my life.
   Will not get pregnant for at least 1 year after my gastric bypass surgery.


This is an agreement of partnership between myself, my surgeon, and my nurse coordinators.


Signature of patient
Date

Surgeon
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