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Dear Prospective Patient,

Thank you for inquiring about weight loss surgery. Since 1979 we have specialized in performing a

well-known and very successful surgical weight loss procedure called Roux-en-Y Gastric Bypass. We

also perform the Gastric Banding, Gastric Sleeve, and Duodenal Switch procedures. Over the years

our patient base has grown to over 18,500 patient surgeries. We are happy to have one of the largest

and most successful bariatric practices in the country.

Enclosed you will find details about weight loss surgery, biographies of each of our surgeons and

information regarding the process of obtaining weight loss surgery from Rocky Mountain Associated

Physicians (RMAP). It is very important that you sit down and read the information in its

entirety to help us provide you with the best service possible.

Whether you are self paying for your surgery, or seeking authorization from your insurance company,

please follow the detailed instructions. This will show you all the information you need to gather. We

will not be able to proceed with your request for weight loss surgery without all required information. If

your paperwork is incomplete it will be sent back to you for completion.

Our office will communicate with you through e-mail, as this has proved to be the most efficient way

to update one another. If you have not provided us with an e-mail address, we will send you the initial

correspondence through regular mail.

If you have any questions, please contact us at 1-800-999-9970 or 801-268-3800 or email us at

info@rmapinc.com.

Sincerely,

Rocky Mountain Associated Physicians Team

1160 East 3900 South, Suite 4100

Salt Lake City, Utah 84124 / Toll-Free 800-999-9970 Phone 801-268-3800 / Fax 801-268-3997

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Rocky Mountain Associated Physicians

The Patient Steps to Weight Loss Surgery

For Insurance Patients

You will need to follow the steps below to obtain weight loss surgery from our office: 1. Attend “The Risks and Benefits of Weight Loss Surgery” Class (Required Class)

You may have already attended this class. Here, you will receive an information packet, as well as specifics regarding all four surgical procedures. Part of this class is taught by one of our surgeons. It is required for all patients who live inside a 200 mile radius of Salt Lake City. (1 to 2 hour meeting). For those living outside of that radius, we offer this class ‘live’ online twice a month.

2. Turn in your completed packet, along with a copy of the front and back of your insurance card, to our office. Make sure that you select a Surgeon as well as the procedure that you are most interested in.

3. We will then send you emails within a day or two from our office, (if an email address is not provided, this information will be mailed to your home address.

a. The first will inform you that we have received your packet, and have begun the process of checking into your insurance.

b. The second will let you know if your insurance coverage has weight loss surgery benefits. If so, this email will also include their requirements which you will need to complete prior to obtaining an approval for your surgery. If your insurance coverage does not include weight loss surgery, this email will inform you of our Private Paying options that we offer.

4. Start working on the insurance requirements that we informed you of. ALL insurance policies are different and have unique requirements. The above email will give you contacts of providers that we work with if needed. As soon as you have the documents of the completed requirements, send them to our office, attention Christina.

5. When we have received all of the documentation for the required tasks, we will call you to schedule your Physician Consultation - Informed Consent and Awareness Class. Here you will be taught more about your surgery, as well as undergo an examination to ensure that you are ready for surgery. Please plan the entire morning or afternoon. You may be in our office 3 to 4 hours. Due to the length of time, we ask that you please do not bring your children.

6. The ‘Consultation’ is the last requirement from your insurance company. We will then include the Physician notes with your packet and send it to your insurance company for a prior authorization approval request. (The average response time is 1-2 weeks to hear back from them. They have up to 30 days to respond).

7. Once approved, we will notify you by phone and schedule your surgery. Cathy, the surgery Coordinator at RMAP, will call you to schedule your surgery date, as well as the “Surgery Orientation Class”.

Please note: Once your surgery is scheduled you may not change the date! Only your surgeon

may change the date. There are too many complicating factors associated with changing the schedule for Weight Loss Surgery with the hospital, surgeon and insurance. Please do not expect your date to be changed for any reason once you are scheduled.

8. Attend Surgery Orientation Class at RMAP (Required Class). Provide Payment.

Here, you will learn what is necessary for your surgery…”The Do’s and Don’ts”. You will also hear from a Registered Dietician to discuss dietary guidelines. Your Education Materials will be given to you. We’ll also take a “Before” picture for you to place in your booklet. Deposits are due at this time as well. (2 ½ hour meeting)

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Insurance Patients 100% Coverage 90% 80% 70% 60% 50% Medicare Surgeon Deposit 0 $500 $1000 $1500 $2000 $2500 $420 Assistant Surgeon Deposit 0 $100 $200 $300 $400 $500 $ 64 Education Program $500 $500 $500 $500 $500 $500 $500 Total Deposit $500 $1100 $1700 $2,300 $2900 $3500 $984

Make Payable to Rocky Mountain Associated Physicians. (Major Credit Cards are accepted, along with cashier checks, or money orders. No personal checks please).

* If your insurance covers 50% or less please contact the hospital to get an estimate of what your hospital charges will be. All hospital charges vary.

9. Have your surgery.

10. Attend an “Emotional Support” class held two to four weeks after your surgery.

This class is taught by a LCSW and weight loss surgery patient as well. Here you will learn important keys in successfully managing the emotional side of eating and comfort.

Additional Billing and Payment Information

- PLEASE READ CAREFULLY -

Office Visits Gastric Bypass, Sleeve and D. Switch- For self-paying patients the initial office visit consultation is a $200 deposit which is applied toward the surgery fee. If you have your consultation with the physician(s) and decide not to have surgery the $200 will be used to cover the office consultation visit. After your surgery you will receive 1 year of office follow-up visits at no charge.

Office Visits Lap Band- For self-paying patients the initial office visit consultation is a $200 deposit which is applied toward the surgery fee. If you have your consultation with the physician(s) and decide not to have surgery the $200 will be used to cover the office consultation visit. Band adjustments are included as part of surgery for the first 12 months. Following the first year, Band adjustments will incur a charge of $100 in the office and $225 if the adjustment requires radiology services at the hospital.

For Patients Covered by Insurance – Routine follow up visits for insurance patients will be at no charge for the first 90 days depending on provider contracts with insurance. After 90 days the office visit co-pay will be due at the time of service. Should a Lap Band Adjustment be needed, insurance authorization is necessary prior to the adjustment. Lap Band adjustment charges may be processed to your deductible. Regular Co-Pay charges will be due at the time of the visit.

Any additional procedures associated with the follow up office visit will incur a charge (i.e. B12 injections etc.). Additional office services are not part of the “no” charge policy for self-pay patients.

You are financially responsible for all charges whether or not your insurance company pays. If you have any billing questions, please contact your surgeon’s office.

Please Note: For cash pay patients, if the insurance pays for your office visit(s) RMAP will accept that money as payment for the office visit and is not refundable.

Medicare / Medicaid Patients: We are not providers of Medicaid for patients who live outside of Utah. Returned Checks will incur a $20.00 service charge.

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Rocky Mountain Associated Physicians

RMAP

The Patient Steps to Weight Loss Surgery

Self-Pay Patients

If you do not have insurance that covers weight loss surgery, here are the steps for you to complete: 1. Attend “The Risks and Benefits of Weight Loss Surgery” Class (Required Class)

This class is required for those who live inside a 200 miles radius of Salt Lake City. You may have already attended this class. You will receive an information packet at this meeting. Patients living outside a 200 miles radius of Salt Lake City have received the necessary paperwork and information contained in this packet by mail. (1 to 2 hour meeting)

2. Fill out and turn in your paperwork to Rocky Mountain Associated Physicians Office

Include with your paperwork all the necessary information listed on the “Self Pay Patient Check List”, which is at the bottom of this page. If you need additional assistance, please call RMAP to make an appointment with Christina, your Patient Advocate, who will review your paperwork and answer your questions. *Once your paperwork is submitted, the doctor will review it and we will be in contact with you to schedule your consultation.

3. Physician Consultation and Informed Consent Class (Required Class)

We will contact you to schedule your consultation, as well as schedule you for the Informed Consent and Awareness class. This class will be the same day as your consultation with your surgeon. A $200 payment is due for your Physician Consultation at the time of service. If you proceed with surgery the $200 will be applied toward your surgery deposits.

Please plan the entire morning or afternoon for the class and consultation. Immediately following the class, your surgeon will meet with the class as a group, and then individually. You may be in our office 3 to 4 hours. Due to the length of time, we ask that you please do not bring your children.

* All patients wanting Gastric Banding surgery must attend this consultation, regardless of where you live.

4. Attend Surgery Orientation and Education Class at RMAP (Required Class). Provide Payment. Here, you will learn what is necessary for your surgery…”The Do’s and Don’ts”. You will also hear from a Registered Dietician and Social Worker to discuss dietary and emotional guidelines. Your education materials will be given to you. We’ll also take a “Before” picture that will be ready for you at your first follow up appointment. The total cost of surgery is due at this appointment. (2 ½ hour meeting)

5. Attend an “Emotional Support” class held two to four weeks after your surgery. This class is taught by a LCSW and weight loss surgery patient as well. Here you will learn important keys in successfully managing the emotional side of eating and comfort.

SELF PAY PATIENT’S CHECK LIST

Completed

Completed RMAP Patient Information Form

Yes No

Completed RMAP Medical History Form

Yes No

Selected your Surgeon and Procedure

Yes No

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Self Pay Costs

June 2015

Gastric Bypass 43644 Gastric Banding 43770 Gastric Sleeve 43775 Duodenal Switch 43845 Physician Consultation $200 $200 $200 $200 *Surgeon Fee (Less $200 Consultation) $ 5,765 $ 4,300 $4,300 $7,240 Anesthesiologist Fee $ 1,100 $ 880 $880 $1,100 Assistant Surgeon Fee $ 1,200 $ 900 $900 $1,500 Education Program

(Required) $500 $500 $500 $500

Total to R.M.A.P. $8,765 $6,780 $6,780 $10,540

All above payments should be payable to “Rocky Mountain Associated Physicians”, when you attend the Surgery Orientation class at RMAP.

Hospital Fee Inpatient

St. Mark’s LDS $10,660 $10,600 $8,450 $8,545 $9,700 $10,275 $ 16,995

Outpatient (certain criteria applies)

$6,280

Inpatient fees payable to the hospital where your surgery is to be performed. Outpatient

Fees should be combined with surgeon fees and made payable to “Rocky Mountain Associated Physicians”.

Grand Total Fees St. Mark’s LDS St. Mark’s Outpatient $19,425 $19,365 $15,230 $15,325 $13,060 $16,480 $17,055 $27,535

All payments are required when you attend the Surgery Orientation Class! (Credit Cards Accepted)

All Payments are Required Prior to Surgery

All payments and deposits are due prior to surgery for surgeon’s office and Hospital.

Hospital and surgeons office requires all deposits in the form of a cashier’s check, money order or credit card. (No Personal Checks).

Pay the hospital fee to the hospital separately. Outpatient Surgical Center is paid to RMAP.

The surgeon retains $25.00 for the collection of Anesthesia and Outpatient Surgical Center fees for self pay patients. Please note: If surgery takes longer than normal you may be billed for additional Anesthesia time by the Anesthesiologist.

You might receive an invoice from Utah Imaging Pathology should they be required to assist with x-rays. They are not associated with the hospital, and bill separately. They offer our patients a discount, and charges are usually between $50 and $150.

The prices quoted above are for weight loss surgery only. Other services may be required that are not listed above i.e. radiology, pathology etc. Any other procedure i.e. gallbladder removal, hernia repair, etc., performed at the time of surgery will be billed as secondary procedures and there may be additional charges. Gastric Banding patients may receive additional charges from a radiologist for reading the barium swallow results associated with surgery.

- Charges can vary according to circumstances and are subject to change without notification.

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Self Pay Patients

Complication Coverage – St. Mark’s Hospital

We are happy to announce that effective 4-1-2014; the hospital fee for the Gastric Bypass, Gastric

Band, Gastric Sleeve, and the Duodenal Switch

at St. Mark’s Hospital includes financially covering

most complications. This was done to give private paying patients peace of mind, minimizing the

financial worry should a complication arise. Here are the details:

Gastric Bypass

$10,660 Hospital Fee

Complications covered include: Cardiopulmonary events, Thromboembolic

events, Bleeding, Infection, Leaks, Perforations, Obstructions, and Stenosis.

Complications can occur anytime from the day of surgery through 90 days. The

cap amount is $100,000. Should they go over that amount, they pay 25% of

charges.

Gastric Band

$8,450 Hospital Fee

Complications covered include: Cardiopulmonary events, Thromboembolic

events, Bleeding, Infection, Leaks, Perforations, Obstructions, Band Erosion,

Band Slip, and Port Site Problems. Complications can occur anytime from the

day of surgery through 90 days. The cap amount is $30,000. Should they go

over that amount, they pay 25% of charges.

Sleeve Gastrectomy

$9,700 Hospital Fee

Complications covered include: Cardiopulmonary events, Thromboembolic

events, Bleeding, Infection, Leaks, Perforations, and Stenosis. Complications

can occur anytime from the day of surgery through 90 days. The cap amount is

$100,000. Should they go over that amount, they pay 25% of charges.

Duodenal Switch

$16,995 Hospital Fee

Complications covered include: Cardiopulmonary events, Thromboembolic

events, Bleeding, Post Operative Infection, Leaks, Perforations, and Stenosis.

Complications can occur anytime from the day of surgery through 90 days. The

cap amount is $100,000. Should they go over that amount, they pay 25% of

charges.

The fee stated above includes the coverage for complications. The fees mentioned above cover St.

Mark’s Hospital, Surgeon and Assistant Charges. These are the majority of financial charges for

complications.

It is important to note that this financial coverage does not include charges from

independent providers, even those who might treat you at St. Mark’s hospital.

Examples of Non Covered Charges would be:

E.R. Physicians - Anesthesiologists - Radiologists as well as specialist

fees, or any provider that bills outside of St. Mark’s Hospital.

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LDS Hospital

Metabolic and Bariatric Surgery Self-Pay Patient Financial Agreement INSURANCE HAS DENIED COVERAGE FOR GASTRIC PROCEDURE:

____(Please initial here)

Your insurance has denied coverage for your gastric bypass procedure. You will be registered in our system as a self-pay patient. Your insurance will not be billed for any services provided in conjunction with the gastric bypass or lap banding procedures.

LAPAROSCOPIC GASTRIC BYPASS PROCEDURE: ____(Please initial here)

You are having a laparoscopic gastric bypass procedure. You have made a $10,600 deposit, and if there are no complications, your procedure will be considered paid in full. Complications are defined as any laparoscopic gastric bypass procedure with charges in excess of $100,000. If the charges exceed $100,000 (considered “complicated”) you will be responsible for 60% of the charges in excess of $100,000. Your initials indicate that you have been verbally counseled regarding the final charges for the laparoscopic gastric bypass procedure and understand that if necessary you are responsible to make financial arrangements with one of our Patient Account Services representatives upon receipt of your bill.

LAPAROSCOPIC SLEEVE GASTRECTOMY PROCEDURE: ____(Please initial here)

You are having a laparoscopic sleeve gastrectomy procedure. You have made a $10,275 deposit, and if there are no complications, your procedure will be considered paid in full. Complications are defined as any laparoscopic gastric bypass procedure with charges in excess of $100,000. If the charges exceed $100,000 (considered “complicated”) you will be responsible for 60% of the charges in excess of $100,000. Your initials indicate that you have been verbally counseled regarding the final charges for the laparoscopic gastric bypass procedure and understand that if necessary you are responsible to make financial arrangements with one of our Patient Account Services representatives upon receipt of your bill.

LAPAROSCOPIC GASTRIC LAP-BAND PROCEDURE: ____(Please initial here)

You are having a gastric lap-band procedure. You are making a $8,545.00 payment today and if there are no complications, your procedure will be considered paid in full. Complications are defined as any lap-band procedure with charges in excess of $100,000. If the charges exceed $100,000 considered “complicated”) you will be responsible for 60% of the charges in excess of $100,000. Your initials indicate that you have been verbally counseled regarding the final charges for the lap-band procedure and understand that if necessary you are responsible to make financial arrangements with one our Patient Account Services representatives upon receipt of your bill.

LAPAROSCOPIC GASTRIC LAP-BAND REMOVAL PROCEDURE:

____(Please initial here) You are having a gastric lap-band removal procedure. You are making a $2000.00 payment today and if there are no complications, your procedure will be considered paid in full. Complications are defined as any lap-band removal procedure with charges in excess of $100,000. If the charges exceed $100,000 considered “complicated”) you will be responsible for 60% of the charges in excess of $100,000. Your initials indicate that you have been verbally counseled regarding the final charges for the lap-band procedure and understand that if necessary you are responsible to make financial arrangements with one our Patient Account Services representatives upon receipt of your bill. If you receive additional hospital services following discharge from your gastric procedure, those services

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Rocky Mountain Associated Physicians

Support Group

Support Groups are designed to bring patients together to support, share, and work together. We are

excited to offer the opportunity to help guide you on this exciting journey through weight-loss surgery

to a happy and healthier lifestyle.

Support Groups are held on varying Wednesdays from 6:30-8:00 pm in our Education Center, located

in Suite 4200 of the North Medical Building at St. Mark’s Hospital. All Support Groups are included in

your Education Program, paid with your bariatric program fee at the time of your surgery.

We would love to see every future and past patient taking advantage of the opportunity to share and

learn from each other. We hope you will join us.

Stage I - Early Weight Loss Group. This group includes patients who have had surgery but are less

than six months out from their surgery date. This group focuses intently on supporting and helping

new patients as they adjust to the many changes they face after surgery. Questions and concerns

about the early stage of weight loss will be answered. This group is held on the first & second

Wednesday of each month from 6:30 until 8:00 p.m.

Stage II - Weight Loss Group. This group is for patients who are six months out from their surgery

date and still in the weight loss phase. This group focuses on identifying habits, thinking errors,

self-defeating beliefs, and unresolved emotional issues which, if left untreated, are likely to sabotage the

patient’s long-term success. Patient’s are encouraged to meet their weight loss goal and carefully

directed in how to approach the maintenance phase successfully.

This group is held on the third Wednesday of each month from 6:30 until 8:00 p.m.

Stage III - Maintenance Group. This group includes patients who are finished with the weight loss

phase and are in the maintenance phase. This group focuses intently on helping patients adjust to

maintenance without excessive weight gain. Questions and concerns about the lifetime commitment

to weight loss maintenance are the focus.

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RMAP Education Program $500-

(Not Covered by Insurance)

RMAP Education Binder ($150 to replace)

1. Pre Surgery Information

 Pre Surgery Information Brochure and Patient Information Forms  Risks and Benefits Printed Materials

 Informed Consent Printed Materials  Pre Surgery Orientation Printed Materials

2. Post-Surgery Information

 Patient Guidelines Summary ($35 to Replace)  Other Printed Educational Materials

 Support Group

3. Miscellaneous Materials

 Daily Food Journal Form  Menu Planner Form

 Grocery Shopping List Form

 Weight and Measurement Tracking Form  Vitamins List

 BMI Chart

 Internet Resources Information  Post Op Log

 Therapist List

Picture Booklet / Reminder Card Holder ($15 to replace)

 Medical / Restaurant Card

Use this at other physician offices or hospitals to show your anatomy and or procedure. It will be helpful for other physicians to understand your new gastric pouch while providing you with treatment.

 Reminder Cards

These cards are designed to be quick references to help remind you of the types of food to eat hydration requirements etc. You may want to keep them with you in your planner or purse.

Picture and Video CD ($5 for replacement)

You will receive a CD with your before surgery photo. We encourage you to take pictures of your progress as reminders of the success you are having at different stages. We will take a picture at your one year visit and provide you with another CD at that time. The CD will also contain video you can watch on your computer of special Salt Lake Support Group presentations.

Education and Classes ($350)

1. The Risks and Benefits of Weight Loss Surgery Class 2. Informed Consent and Awareness Class

3. Pre Surgery Orientation Class

4. One year paid membership “Obesity Action Coalition”

5. Support Group Coordination and Presentations (Lifetime)

6. Group Therapy – Dealing with emotional challenges. (Nine sessions offered per year. Unlimited

participation).

7. RMAP Telephone Support from the Education Department (During Business Hours) 8. Internet Based Support which Includes:

*Patient Support Forums *Online Newsletters and Information *Electronic Communication with RMAP Office *Patient Chat Rooms *On line access to Patient Medical Record (Secure Access)

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STEVEN C. SIMPER, M.D., F.A.C.S.

“It is the will and ambition of our patients who ultimately make their weight loss possible.

Treating the Whole Person is a critical part of the care given to my patients.” - Steven C.

Simper

Dr. Simper’s expertise and passion are in performing minimally

invasive laparoscopic surgery. His first bariatric procedures were

in 1984 at Wilford Hall Medical Center, in Texas.

He joined Rocky Mountain Associated Physicians in 2001, at the

time in which laparoscopic bariatric surgery was in its infancy.

Over the years, with continuing education and preceptorships he

has added the gastric banding, laparoscopic duodenal switch,

and revisional bariatric surgery to his repertoire.

He was a presenter at the 2006 and 2007 National Bariatric

meetings (ASMBS), and is active in publishing papers and

furthering knowledge as to the surgical treatment of obesity.

His education, training and qualifications include:

 American Board of Surgery – Board Certified General Surgery

 American Board of Surgery – Board Certified Vascular Surgery

 Phi Beta Kappa Honor Society – University of Utah (BS Biology)

 University of Utah School of Medicine – Top 10% of Class – ROTC Air Force Scholarship

 General Surgery Residency – Wilford Hall Medical Center – USAF San Antonio, TX

 Top Surgical Intern

 Non-Cardiac Thoracic and Surgical Critical Care Fellowship – Biloxi VA Hospital, MS

 Compassionate Physician of the Year 1988

 Vascular Surgery Fellowship – Pennsylvania Hospital, Philadelphia, PA (1992-1993)

 Staff Surgeon – Incirlik, Turkey – USAF (1987-1988)

 Chief of Thoracic and Vascular Surgery, Scott AFB, IL (1989-1992)

 American Society of Bariatric and Metabolic Surgery – Member

Dr. Simper is a native of Brigham City, Utah. After fulfilling his Air Force commitments and training,

he returned to Utah in 1999 to be closer to his family and the outdoors. He has six children, and his

avocations include reading, fishing, and mountain biking, hiking and hunting.

Dr. Simper

“If life were fair…I’d be thin,

And you’d be fishing”

(Patient’s Quote)

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RODRICK D. MCKINLAY, M.D., F.A.C.S.

Dr. Rodrick McKinlay joins Rocky Mountain Associated Physicians as a board certified general

surgeon with expertise in minimally invasive—or laparoscopic—

surgery. In addition to the surgical treatment of obesity, his

practice involves a wide range of minimally invasive

gastrointestinal surgery, including hernia repair, gallbladder

removal, anti-reflux surgery, and the surgical treatment of

spleen

and

adrenal

disorders.

Dr. McKinlay graduated summa cum laude from Brigham Young

University in 1993 and then received his medical degree from

the University of Utah in 1997, where he graduated with honors

in medicine and surgery. After completing General Surgery

residency at the University of Arizona, he began a minimally

invasive surgery (MIS) fellowship at the University of Kentucky,

focusing on research in MIS. He concluded the clinical portion

of

the

fellowship

at

the

University

of

Maryland.

Dr. McKinlay is Board Certified in General Surgery. He is a

Fellow of the American College of Surgeons. In addition to

striving for top-quality surgical care using the latest technology, Dr. McKinlay emphasizes treating the

whole patient with respect and attention to detail. Seeing the change that can occur in a patient's life

after weight loss or other surgery is what he enjoys most about caring for patients.

He loves to spend time with his family, especially in the outdoors. He particularly enjoys playing

soccer, running, and skiing. Fluent in Spanish, he also enjoys literature and the arts.

Gastric Bypass, Gastric Band, Gastric Sleeve, and Duodenal Switch Surgeon

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Register on our Website

www.utahbariatrics.com

All prospective patients are welcome to register on our website.

As a registered user you can chat with other patients or ask questions through the forums etc. We

feel it is important for prospective patients to communicate with current patients that have already had

the surgery. This helps you understand both the successes and difficulties patients have experienced,

giving you a full understanding of how the surgery can benefit your situation and what to expect.

Registration Instructions:

 In your web browser go to

www.utahbariatrics.com

.

Click on “New User” in the top right corner.

 Simply follow the instructions as it is self explanatory.

 During the registration process you will provide basic demographic information.

 You will also be able to create your own username and password.

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