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Missouri Bariatric Services does accept revision surgery candidates on a case by case basis. Each revision case is reviewed by the Missouri Bariatric Services Clinical Committee, consisting of our surgical and medical team. If you have received previous weight loss surgery, please complete the form below for consideration.



* Indicates required information
First Name * 
Last Name * 
Email address * 
Phone number * 
Date of Birth *    (mm/dd/yyyy)
Date of original weight loss surgery: *    (mm/dd/yyyy)
Name of your original surgeon: * 
In which city and state did you receive your surgery? * 
What type of procedure did you have? 

If Other, please specify:

What was your highest weight prior to your bariatric surgery? * 
What was the lowest weight you acheived after your bariatric surgery? * 
What is your current weight? * 
Do you have pain when you eat? 
Are you able to tolerate liquids? 
Do you have nausea/vomiting when you eat food? 
Do you have nausea/vomiting without eating food? 
Are you experiencing gastroesophageal reflux? 
Are you experiencing heart burn? 
Are you having general pain? 
If yes, where is the location of your pain? 
Are you currently smoking? 
Do you use NSAIDS (ibuprofen included)? 
Are you, or have you been on long term steroids? 
Have you ever been told you have a gastro/gastric fistula? 
Are you seeking help to deal with weight regain following your bariatric surgery? 
Are you wanting to establish general bariatric care with our clinic (no revision)? 
Are you seeking a revision to your previous bariatric surgery? 
 



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