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McMinnville Surgical Associates 254 NE Norton Lane McMinnville,

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McMinnville Surgical Associates
254 NE Norton Lane
McMinnville, Or 97128
P: 503-434-6060
F: 503-435-6463
Name: ___________________________________ Date of Birth: ______________
Mailing Address: _____________________________________________________
Apartment Number: __________________________________________________
City/State/Zip:_______________________________________________________
Phone #:_______________________ Alternate Phone #________________
Email:______________________________________
Height: ______________
Weight: ______________
Diabetic: YES NO
Medication? _____________________________________________
Smoking Status: Never Current
Former Stop date: _______________
Comorbidities: High Blood Pressure High Cholesterol Sleep Apnea
Other: ______________________________________________
How did you hear about our program? (Please list specific providers so we can thank
them for the referral)
____ Friend ____ Newspaper Ad
____ Family Member ____ Call to McMinnville Surgical Associates
____ Doctor _____________ Other ______________________________
Primary Insurance
Insurance Company __________________________________________________
Id # __________________________________Group # ______________________
Address: ___________________________________________________________
Phone # ______________________________
Card Holder: ________________________ Card holder date of birth: ___________
Secondary Insurance
Insurance Company __________________________________________________
Id # __________________________________Group #______________________
Address: ___________________________________________________________
Phone # ______________________________
Card holder: _________________________ Card holder date of birth: ___________
For questions regarding insurance coverage, please call Kendy at 503-434-6060.
I hereby give consent to McMinnville Surgical Associates to contact my insurance
provider on my behalf to inquire about bariatric surgery requirements.
_____________________________________ ___________
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McMinnville Surgical Associates 254 NE Norton Lane McMinnville,

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Completed 9 February 2021

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