The Lap Band is a device approved for marketing in the United States to assist in weight loss. There are certain indications for the use and marketing of this device that have been approved by the Food and Drug Administration (FDA). Uses of the Lap Band that are not approved by the FDA include its use in patients with body mass index (BMI) less than 35, use in patients under the age of 18, and its use in patients with certain diseases. I have been provided with a book that lists these conditions and by signing this acknowledge that I will discuss any concerns or questions of off-label uses with my surgeon. It is my choice to have the band placed, even if the government, through the Food and Drug Administration has not certified this as a use for the band.

With the Lap Band you need to take a multivitamin daily. The National Academy of Science recommends that adults all take a multivitamin daily. Further, you still need to make certain you are getting enough other nutrients, such as calcium. You must take vitamins for THE REST OF YOUR LIFE.

The pre-operative psychological evaluation is not a screening tool to determine eligibility for the Lap Band, nor can this evaluation determine if you will succeed or fail with the Lap Band. Success is up to you. You choose what you eat, when you eat, and it is not determined by any test, or pre-condition.

The psychological evaluation is to introduce you to a professional that may assist you after you have surgery. You cannot blame the therapist if you do not succeed, but you can use the therapist to help you get back on tract. If you have mental health issues like depression, bi-polar, anorexia, bulimia or other mental health illness you must not hide these problems. By signing this you have filled out the history form accurately and disclosed any mental health problem and will disclose them in your pre-operative evaluation. By signing this you attest that you do not take drugs that are illegal and that you do not have an alcohol problem, or drink excessively.