Beltline Win Back Beltline Win Back Campaign Form Your Name First Last Your Email Here at Beltline, we stand behind offering you comprehensive (and accessible!) long-term support after surgery. We would love to give you an opportunity to extend your time inside our virtual After Care Program through Banana Bariatrics! Below, you will find different means of “collecting” Points. Each action item below is allotted a unique number of Points. To earn points, you must complete all relevant sections within each action item. All answers may be internally reviewed for verification purposes. After collecting > 6 Points, you will be awarded a unique Beltline Coupon Code that will grant you 6 additional months inside Banana Bariatrics. We hope to see you inside the After Care Program again soon!ACTION ITEM #1POINTS = 2 per Contact addedRefer a family member / friend / colleague to Beltline Health for surgical, medical, or overall weight loss support.How many contacts will you be referring?(Required)012345Enter a family member / friend / colleague details… Name Actions Edit Delete There are no Contacts. Add Contact Maximum number of contacts reached. 2 POINTS PER CONTACT*IMPORTANT: By providing contact information for each person below, you acknowledge that you have obtained verbal consent from each referral that it is okay for Beltline to reach out to them for further inquiry.ACTION ITEM #2POINTS = 1In the past 3-6 months, have you completed (or have an upcoming) Appointment scheduled with Beltline either Virtually or In Office? Virtually In Office Please enter completed date of (or upcoming scheduled) clinic visit: MM slash DD slash YYYY ACTION ITEM #3POINTS = 1 for either Option A or Option BBeltline requires a full bariatric panel of lab work every 6 months. Do you have lab work or need to schedule an upcoming panel of labs? Yes Complete either Option A or Option B: A) If you have completed labs in this time frame, please fill out the information below:Lab Facility where your labs were recently collected at:Date of last completed lab draw: MM slash DD slash YYYY OR B) If you are due for labs, please call our Office at: (470) 419-4380 to schedule a clinic visit with one of our Providers so we may assist you in ordering and following up on your lab results. Date of upcoming clinic appointment: MM slash DD slash YYYY ACTION ITEM #4POINTS = 1Write a Google Review showcasing what you love most about Beltline Health and the care you have received as a patient. 5 Star Reviews go a long way- we appreciate your consideration! Simply Google “Beltline Health” and on the right hand column, scroll down to “Reviews” and click the “Write a Review” button.Check the box below once you have submitted your Google Review: Done! ACTION ITEM #5POINTS = 1Purchase your full Bariatric Vitamin regimen through our Beltline website and ensure you are taking your vitamins 7 days per week: Sleeve / Bypass: ProCare multivitamin with 45mg iron + 3 calcium citrate chewys / day SADI / Switch: ProCare DS/SADI multivitamin with 60mg iron + 4 calcium citrate chewys / day Beltline Vitamin Link: https://beltlinehealth.com/vitaminsCheck the box below once you have purchased all required Vitamins: Yes- I have purchased my Bariatric multivitamin, iron (ADEK), and calcium supplements! ACTION ITEM #6POINTS = 1Have you attended one of our recent Monthly Beltline Support Groups in Atlanta, Newnan, or Stockbridge either Online (Zoom) or In Office? Yes Date of Recent Support Group Attendance: MM slash DD slash YYYY LocationACTION ITEM #7POINTS = 1Have you been struggling with reflux? Yes We encourage you to review the following list of symptoms pertaining to reflux and risk factors for Barrett’s esophagus (a pre-cancerous form of esophageal cancer). If any of these risk factors apply to you, and you haven’t spoken with one of our providers about your heartburn symptoms yet, we strongly recommend making an appointment with us to help you feel better and to discuss possible screening options! REFLUX: Acid reflux/ heartburn – or you take medication for it Family history of Barrett’s esophagus or esophageal cancer Age > 50 years old BMI > 30 Male White Current / former smoker Exposer to smoke (ie: work as a firefighter) Call our Office at: (470) 419-4380 to schedule a REFLUX CONSULT with one of our providers so we may assist you with your symptoms. Date of upcoming REFLUX Consult appointment: MM slash DD slash YYYY ACTION ITEM #8POINTS = 1Do you have concerns with your legs? Yes Please review the following list of symptoms pertaining to the health and integrity of the valves in your veins. If any of these symptoms apply to you, and you haven’t spoken with one of our providers about your symptoms yet, we strongly recommend making an appointment with us to help you feel better and to discuss possible screening options! VEINS: Leg swelling Restless leg syndrome Achiness / tiredness in your legs throughout the day Varicose veins Compression stocking use Call our Office at: (470) 419-4380 to schedule a VEIN CONSULT with one of our providers so we may assist you with your symptoms. Date of upcoming VEIN Consult appointment: MM slash DD slash YYYY This field is hidden when viewing the formScore Count
