Patient Forms

The following PDF forms will need to be completed for your first visit to our office. You are welcome to print them from our website and bring them with you to your scheduled appointment.

We also invite anyone who visits this page—whether you’re one of our patients or not — to download Baritastic, a free app that allows you to engage with our program while also tracking food and other bariatric program activities.

Complete your forms using MyChart. Main Line Health MyChart makes it easy for you to schedule appointments, request prescription refills, pay your bills, send messages to your doctor’s office when you have non-urgent medical needs, and more — from any device.

Complete Forms Using MyChart

New patient forms

Medical weight management health packet

Bariatric surgery health packet

Patient signature on file form

Patient demographic data sheet

Instructions for authorization to disclose protected health information (PHI)

Authorization to disclose protected health information (PHI)

Patient financial policy form

Main Line Health notice of privacy practices

Acknowledgement of receipt – MLH notice of privacy practices

Non-discrimination and availability of services notice

No show policy form

Established patients

Care for the post-op bariatric surgery patient

Vitamin and mineral requirement guide for the post-op bariatric surgery patient

To request a copy of your medical records:

• Authorization for release of medical information form

For your convenience, we have also included a link to a commonly requested form:

• PennDot handicap parking placard application