Referring Patients

Together, we can make a difference.

The entire New Dimensions practice is focused on helping patients achieve better health through substantial and sustained weight loss.   We can provide the attention of specialists if you have gotten your patient started on their weight loss journey, or we can start at the beginning if that works better.  Our experience is that many patients don’t know whether they need medical or surgical solutions, so we are ready to help them decide how to begin and to offer additional options as they make progress.

Because many patients suffering from obesity also show multiple co-morbidities such as diabetes, hypertension, stroke, sleep apnea, liver disease and heart conditions, surgical candidates must be carefully screened and monitored. You can trust that your patient will receive the best care and attention based on the most current science.

After surgery, patients require life-long monitoring for nutritional deficiencies and short- and long-term complications. New Dimensions works with a patient’s primary care physician to offer continued support, compassionate long-term care, and guidance throughout the patient’s life.


Surgical Candidates
Why New Dimensions

Patient Referral Form

(* denotes required field)
Referring Doctor*
Referring Phone Number*
Referring Email


Patient Information

Name (First Last)*
DOB (MM/DD/YYYY)*        
Primary Insurance name (We take all insurance)*
Height (inches)*
Weight (lbs)*

Contact Information

Preferred Phone (555-555-5555)*
Other Phone
Email*


Current Medical Problems (Check all that apply)

 Diabetes
 Sleep Apnea
 Patient uses CPAP
 Asthma, Reactive Airway Disease
 Heart Failure
 Angina, Coronary Artery Disease
 Gallstones
 GE Reflux Disease (GERD)
 Arthritis
 Back Pain

Venous Thrombosis
 DVT PE
 Urinary Incontinence
 Menstrual Irregularity, Infertility
 Hirsutism
 Depression
 High Cholesterol, High Lipids
 Hypothyroidism
 Other Endocrine/Hormone Problem

Cancer (Type)
Other

Evaluation Requested*

Non Surgical Evaluation + Weight Management
 Dr. Sabowitz

Consideration for Bariatric Surgery
 Dr. Pilcher Dr. Reiss

Notes

Comments are closed.