Once you have completed the patient packet completely, you may fax it to our office at: 606.425.4696, or you can scan and email to: LCRH.CBC@LPNT.NET
If you have additional questions please call our office at: 606.676.0455
Patient Intake Packet (PIP) Part 1
A multipage document that needs to be completed in it's entirety. The PIP packet is needed to start the program process.
Physician Referral Form
A form needed for your primary care physician to complete to support your need for weight loss surgery.
Physician Supervised Diet Form for Monthly Visits
A form needed for your physician to complete your monthly diet attempts.
Orbera Gastric Balloon Information
Patient information from Apollo Endosurgery to provide information about the Orbera gastric balloon.
Patient Intake Packet (PIP) Part 2 (Food Assessment)
Food Assessment Form required for nutrition evaluation
Patient Intake Packet (PIP) Part 3 (Psychologist Forms)
Patient Registration Form, Assignment of Benefits Form and Business Policies Form needed for psychologist visit.