Donald D. Davenport JR D.O. 540 W 5 street ste 470 Odessa_ TX

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Donald D. Davenport JR D.O. 540 W 5 street ste 470 Odessa_ TX Powered By Docstoc
					                          Donald D. Davenport JR D.O.
                            540 W 5th street ste 470
                              Odessa, TX. 79761
                                 432-580-8330
                               Fax 432-580-8333


If you have had Bariatric Surgery at another facility and are requesting Dr.
Davenport to take over your care we will need the following before we can
schedule you an appointment.

   1. Your operative report
   2. New patient paperwork
   3. Price sheet agreement
   4. Program requirements


At all appointments a 7-day food diary is required. If you do not have your
food diary your appointment will be rescheduled.

Our program is comprehensive. You will see the Doctor or Nurse
Practitioner and the Registered Dietitian. If you had Lap Band surgery you
will be required to have an UGI. You will not get an adjustment until we
have checked the placement of your band. Office visits are by scheduled
appointments only. If you are having problems please call the office during
regular business hours (Monday-Friday 8-12 & 1-5). Our office is a
specialty clinic that deals in weight loss management and General Surgery.
Any other problems you may experience will need to be addressed by your
family practice doctor.
____________________            ____________
Patient signature                date
                            Donald D. Davenport JR D.O.
                              540 W 5th street ste 470
                                Odessa, TX. 79761
                                   432-580-8330
                                 Fax 432-580-8333

We have established the following guidelines for participation in our program. These
guidelines have been found to promote success in reaching weight loss goals after
Bariatric surgery. There are many surgeons who perform Bariatric surgeries and have
established their own programs. You will find there are vast differences among the
different programs and their requirements. Please review the components of our program
and decide whether or not you will be able to or are willing to adhere to our requirements.

    1. The first visit will be a consultation. No band adjustments are done at the first
       visit. The only exception will be if the band is too tight. At this consultation, we
       will collect a detailed history and do a physical exam. You will also be scheduled
       for an upper GI series to assess your pouch and band placement.

    2. All Bariatric patients are required to keep a daily food diary and bring it to all
       appointments.

    3. We do not typically do band fills under x-ray. We use a step-wise approach,
       based on your perception of restriction and your food diary. Every effort is made
       to give you enough restriction to promote weight loss. However, it may take
       more than one fill to get you to that point. Fills are done only once a month, with
       few exceptions.

    4. If your band is too tight after a fill, you can call and get in the same day if you
       call early enough. Our last appointment is at 4:00pm. Please don’t wait until
       Friday afternoon when you have been having problems for several days. We
       want to minimize any vomiting.

    5. At each visit you will see the Doctor or Nurse Practitioner and the Dietitian.

    1. We expect once monthly appointments, until patterns of consistent weight loss
       and lifestyle changes are demonstrated. After which, alternate spacing of
       appointments can be negotiated.

    2. In addition to dietary changes, participation in physical activity is expected. We
       ask that you spend 30 minutes/day participating in some sort of exercise. If you
       have limitations to your ability to exercise, we will assist you in finding an
       activity to accommodate your limitations.



____________________                 ____________
Patient signature                     Date
                          Donald D. Davenport Jr., D.O.
                            540 W. 5th Street ste. 470
                              Odessa, TX. 79761
                                 432-580-8330
                               Fax 432-580-8333


If you did not have Bariatric surgery by Dr. Davenport


Lap-Band
Initial Consult (no adjustment on first visit)             $331.00
Follow-up visit without an adjustment                      $100.00
Follow-up visit with an adjustment (fluid in or out) $200.00


Gastric Bypass or Other Bariatric surgery
Initial visit                                      $331.00
Follow-up visit                                    $100.00

Emergency Adjustment                               $331.00 cash only
(for non-established patients needing fluid removed on an emergency basis only)




We will file your insurance as a courtesy but full payment will be collected
for each visit. If your insurance reimburses your visit then we will issue a
refund or apply the credit to your next visit.



____________________               ____________
Patient signature                   Date

				
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