Bariatric Surgery

New Patient Forms

Find your care

Our bariatric surgeons use a range of treatments to help you reach weight loss goals and optimize your health. To learn more, call 310-206-0367(Link opens phone app).
Request an Appointment

Bariatric New Patient Forms

Please complete the documents and return them to our office via e-mail (Link opens in new window) or fax(Link opens in new window) prior to your consultation.

If you have any questions, please contact the office at 310.206.0367.

Patient filling out health forms at UCLA

New Patient Health History(Link downloads document) (Link opens in new window)

Email Consent(Link downloads document) (Link opens in new window)

Authorization for Release of Health Information(Link downloads document) (Link opens in new window)

Lifestyle Questionnaire(Link downloads document) (Link opens in new window)

Contact Us

To schedule a consultation with UCLA Bariatric Surgery in Los Angeles, California, call us at 310.206.0367 or fill out our online form(Link is external) (Link opens in new window).

For a physician referral, please call (800) UCLA-MD1 (825-2631).

*Weight loss results can vary depending on the individual. There is no guarantee of specific results. Read full disclaimer.