For Referring Physicians

How to refer a patient

To refer a patient who meets the referral criteria (below) for bariatric surgery, health care providers should fill out the Pediatric Weight Clinic referral form. Please check the “bariatric surgery evaluation” box and then fax the form to the Stanford Medicine Children's Health Referral Center at (650) 721-2884.

Parents will be asked to fill out the Parent Questionnaire (in English) (PDF) or Parent Questionnaire (in Spanish) (PDF) and to bring it to the first appointment.

Referral criteria

Adolescents being considered for bariatric surgery should:

1. Have a Body Mass Index (BMI) ≥ 40 or 140% of 95th percentile BMI or ≥ 35 or 120% of 95th percentile BMI with serious obesity-related comorbidities.
2. Demonstrate commitment to a comprehensive medical and psychological evaluation before and after the surgery.
3. Agree to avoid pregnancy for at least two years after bariatric surgery
4. Be capable of and willing to adhere to postoperative nutritional guidelines and exercise program.
5. Be able to provide informed consent to surgery.
6. If serious psychological diseases or addictions are present, they must be treated and stable for at least six months.

Comorbidities

• Type 2 diabetes mellitus.
• Obstructive sleep apnea.
• Pseudotumor cerebri.
• Hypertension.
• Dyslipidemia.
• Non-alcoholic steatohepatitis.
• Venous stasis disease.
• Significant impairment in activities of daily living.
• Intertriginous soft tissue infections.
• Stress-related urinary incontinence.
• Gastroesophageal reflux disease.
• Weight-related arthropathies which impair physical activity.
• Obesity-related psychosocial stress.