Regina – LAP-BAND® Program Surgical Package

Thank you for booking with SmartShape! In order to facilitate your procedure, please complete the following documents and submit to your Patient Coordinator, three weeks before your scheduled procedure, via fax at 416-619-9530 or via e-mail.

Please note, failure to submit your documents and payment by the due date may result in surgery cancellation.

To access the document, simply click on the icon. If you do not have Acrobat Reader®, click here to download.

pre-op questionnaire

Pre-Op Questionnaire

(Submit by Fax or Email)

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Pre-Op History & Physical

(Submit by Fax or Email)

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Consent Form

(Submit by Fax or Email)

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Patient Care Contract

(Submit by Fax or Email)

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