French version reviewed by Dr Pierre Fournier
This form can be used to refer a patient to the Centre de l’Obésité et du Métabolisme de la Côte. A standard referral letter is also acceptable. Fill in the information available and attach any relevant documents. A report is sent to you after the consultation.
| Referring doctor’s details | Patient’s identity and telephone |
|---|---|
| Name, stamp: | Surname, first name: Date of birth: |
| Telephone, email: | Telephone: |
Reason for referral
- Overall assessment of obesity
- Advice on medication
- Surgical assessment
- Advice on a strategy combining medication and surgery
- Follow-up after surgery, performed in Switzerland or abroad
- Weight regain
- Other:
Weight, height, BMI and highest known weight, if available
| Weight | Height | BMI | Highest known weight |
|---|---|---|---|
| Previous treatment (or see enclosed letter) | Period and duration |
|---|---|
| Dietary support | |
| Supervised physical activity | |
| Psychological support | |
| Obesity medication (which one) | |
| Previous obesity surgery: type of operation, date and hospital |
| Associated conditions and current treatment (or see enclosed letter) |
|---|
Documents already available, enclosed
- Report of any previous operation, if available
- Other documents:
Date and signature:
- Author
- Prepared for the Centre from the sources cited
- References
- See “Scientific sources and references” on this page