Casco Bay Surgery

Bariatric Surgery Program
Birth Control Contract

I have been informed of the dangers of a pregnancy occurring within the first 18 months after gastric bypass surgery. During that time the mother does not get enough nutrition to safely support a pregnancy, putting both mother and baby at high risk for health problems that may be permanent. Early pregnancy also threatens the effectiveness of the operation and can prevent the mother from achieving or maintaining her desired amount of weight loss.

I _________________________________ will use a birth control method for the first 18 months after having gastric bypass surgery.

Method planned _____________________________________________

If pregnancy does occur, I will notify the Bariatric Center immediately so that medical intervention and follow-up can be instituted in an attempt to prevent serious complications to the mother, baby, and gastric bypass operation.

Signed _______________________            Date _____________________

Signed _______________________            Date _____________________

Witness ______________________            Date _____________________

The Bariatric Surgery Center
12 Andover Road
Portland, Maine 04102
(207)-761-5612
Toll-Free: (866)-268-9274
Fax: (207)-253-6073