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Referring Your Pre-Operative Patient to the Bariatric Surgery Program

When you refer a patient to Dartmouth-Hitchcock Medical Center's (DHMC) bariatric surgery program in Lebanon, NH, please provide the following information before your patient's initial evaluation:

  1. Referring Provider Information: Please list your name, phone number, e-mail address, and other pertinent contact information.
  2. Patient Information: All of the following information is helpful for the patient's preoperative evaluation, and is an insurance requirement. We ask that the patient gather this information, and send it to us directly in a packet which is provided to them, rather than your office. Any tests or evaluations done at DHMC, DH Manchester or DH Nashua does not need to be sent.
    • Comprehensive history and physical exam within the past year, to include the following information:
      • Documentation of patient's compliance to previous medical regimens and follow up with your office
      • Current height, weight, BMI, and comorbidities. Weight history over the past 5 years, if available.
      • List of allergies and current medications
      • Screening for treatable causes of obesity
      • A letter from you, indicating your support for your patient to undergo bariatric surgery. The letter should be written on stationary with a letterhead. Please list of non-surgical weight loss attempts. This is required by all insurers. If you have concerns about the patient's compliance, stability or readiness to proceed with bariatric surgery, please advise us as soon as possible.
    • All patients must have at least 3 months of medically supervised dieting within the past year, with consecutive monthly follow-ups documenting weight, height, BMI, diet, and lifestyle modifications. (Some insurers require 6 months of supervised dieting).
    • Any labwork done within the past year, such as fasting glucose, lipid profile and HgA1C (if no labwork has been done, labwork will be done on day of initial program visit).
    • Patients insured by Vermont Primary Care Plus must have an H pylori test (which can be done on the day of initial visit), a history, and a physical exam within six months of surgery.
    The following information is helpful:
    • Copies of any recent visits related to obesity only within the past year
    • Reports of special evaluations or tests IF done in the past, including:
      • Cardiac ECHO, cardiac catheterization
      • Evaluations by an endocrinologist, cardiologist, or a pulmonologist
      • Sleep study/ CPAP trial
    • Patients with poorly controlled diabetes and hypertension should be optimally controlled prior to surgery. Patients who are non-compliant with diabetes care and prescribed medications in general often have poor outcomes following bariatric surgery because of continued non-compliance. An A1C of less than 8.5 is required prior to an initial consultation.
  3. Mandatory tests required before bariatric surgery:
    • A psychological evaluation done by a mental health professional who is knowledgeable about bariatric surgery and eating disorders. A minimum of two visits is required, however ongoing counseling is recommended.
  4. Additional tests or evaluations that may be recommended before surgery (testing/evaluations can be done in the patient's community, or arranged at DHMC):
    • Sleep Center evaluation: suggested for patients who have symptoms suggested of sleep apnea. It is estimated that 80 percent of patients enrolled in bariatric surgery programs have sleep apnea. Treatment for sleep apnea is critical prior to surgery to decrease the risk of peri-and post-operative respiratory complications.
    • Cardiology evaluation: suggested for patients with ASCVD, chest pain, dyspnea at rest, etc.
    • Upper endoscopy for patients with GERD
  5. A clearance from the Bariatric Surgery Team prior to referral or registration for the following individuals:
    • Under the age of 24 or greater than 60. Individuals under the age of 21 and over the age of 70 are currently excluded from our program.
    • History of serious liver, cardiac or pulmonary issues (excluding sleep apnea), complex psychiatric issues or history of cancer.
    • Patients with a history of cancer will need clearance from an oncologist. These patients are presented at the monthly Team meeting.
    • A recent comprehensive physical exam, copy of problem list and medications and letter of provider support should be sent to the Bariatric Surgery Program for review at the monthly Team meeting
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