New Client Onboarding Questionnaire

New Client Onboarding

The objective of this form is to facilitate the configuration of your BariNav instance. We kindly request that you complete all sections thoroughly, providing precise and accurate information that you wish to be displayed in BariNav.

If you have any questions about this form, please email support@bcofa.com.

"*" indicates required fields

First Name*

Last Name*

Bariatric Program Name*

In your best estimation what are your current numbers:

Monthly New Lead Volume

Average Attended to Surgery Ratio (Pull-Through)

Current Annual Surgical Volume (Primary Bariatric Cases)

Current Case Mix (GBP, VSG, DS, etc)

Names, Titles, and Emails of Users Accessing BariNav:

Please reference your contract for the number of user licenses purchased.

What are the biggest pain points your bariatric program is facing right now?

What goals would you like to achieve with the initiation of a patient tracking system?

What types of reports would your program like to see? (See standard reports we already have built in BariNav: https://help.baritotalcare.com/docs/standard-reports-in-barinav)

How many bariatric surgeons are associated with your program?

What are the names of the bariatric surgeons in your program?

Does your program accept Medicare, Medicare Advantage, Medicaid, and Self Pay options?

Select all that apply

Other insurance types you would like listed in BariNav:

Name of the hospital(s) your program is affiliated with:

How many locations does your bariatric program have?

Where are the locations you have programs?

Please also provide addresses

What weight loss services do you offer?

Select all that apply

Other services offered and want listed in BariNav:

Please list out the program's pre-surgical requirements and how you would like them displayed?

What bariatric procedures do you perform and want listed in BariNav as an option for Procedure Type?

Select all that apply

Other bariatric procedures you would like added, or listed differently:

Upload any relevant files that will help our team understand your processes and build out your BariNav environment.

Drop files here or

Max. file size: 1 GB.

This field is for validation purposes and should be left unchanged.

Aborted DS, Sleeve
Aborted DS, GBP
Bypass Revision
Conversion Sleeve to DS
Conversion Sleeve to Bypass
Conversion VBG to Bypass
Conversion Band to Bypass
Conversion Bypass to DS
Duodenal Switch
Endoscopic Sleeve Gastrectomy
Endoscopic Sleeve Gastroplasty
Gastric Balloon
Gastric Band
Gastric Bypass
Gastric Sleeve
Gastric Band Removal
Greater Curve Plication
Revision, GJ Anastomosis
Revision, Reversal of Gastric Bypass
Revision
SADI-S
TORe Procedure
Other