Bariatric surgery qualification form

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Bariatric surgery qualification form

In our response, we will inform you whether surgical treatment is indicated in your case and suggest further steps. Please ensure that the email address you use is private and not accessible to third parties.

The data collected in the form will be used only by the physicians at our clinic, in particular to qualify you for surgery, as well as for statistical calculations and comparative scientific studies.

Thank you for completing the form.

    Bariatric Surgery Qualification Form

    Personal Information




    Which type of procedure are you interested in?

    General Information







    Don't know your BMI? Use our BMI calculator.


    Medical History

    Have you followed a diet to lose weight?

    Have you exercised to lose weight?

    Have you attended support group meetings to lose weight?

    Have you received psychotherapy to lose weight?

    Have you taken medications to lose weight?

    Do you suffer from depression?

    What is the maximum weight loss you have achieved and how long did you maintain it?

    Do you suffer from shortness of breath or sleep apnea?

    Additional Conditions

    Do you suffer from any additional medical conditions? (select your conditions)


    Do you take medications regularly or occasionally (which?)

    Have you ever undergone surgery (when, for what reason, were there any complications)?

    Do you smoke cigarettes or use other tobacco products?

    Comments:

    Information on the Processing of Personal Data:

    1. The controller of your personal data is Zbigniew Mazan, conducting business under the name Zbigniew Mazan Mazan Surgery Clinic, ul. Brzozowa 54, 40-170 Katowice, NIP: 6252029012.

    2. Your personal data will be processed for the following purposes:

    • Maintaining medical records pursuant to Article 9(2)(h) GDPR in connection with Article 24(1) of the Act on Patient Rights and the Patient Ombudsman;

    • Qualification for surgical procedures pursuant to Article 6(1)(b) GDPR and, with regard to health data, Article 9(2)(h) GDPR;

    • Ensuring the exercise of your rights as our Patient, including authorizations for access to medical records and information on health status pursuant to Article 6(1)(c) GDPR in connection with Article 9(3) GDPR and Article 26(1) of the Act on Patient Rights and the Patient Ombudsman.

    3. Recipients of your personal data may include:

    • Providers of organizational and technical services supporting the Mazan Surgery Clinic;

    • Legal and advisory service providers;

    • Persons authorized by you;

    • Authorized employees and physicians providing services at the Mazan Surgery Clinic, bound by confidentiality.

    We do not transfer your personal data outside the European Union.

    If you need additional information, please contact our Data Protection Officer at iod@klinika-mazan.pl, by phone at 32 255 38 32, or in person at Mazan Surgery Clinic, ul. Brzozowa 54, Katowice.