For Referring Physicians

How to refer a patient

To refer a patient who meets the referral criteria (below) for metabolic and Bariatric surgery, health care providers should fill out the Pediatric Weight Clinic referral form. Please check the “bariatric surgery evaluation” box and then fax the form to the Stanford Medicine Children’s Health Referral Center at (650) 721-2884. Please call (650) 723-6439 for more information.

Referral criteria

Children being considered for bariatric surgery should:

  • Have a body mass index (BMI) ≥ 140% of the 95th percentile or 120% of the 95th percentile with serious obesity-related comorbidities.
  • Demonstrate commitment to a comprehensive medical and psychological evaluation before and after the surgery.
  • Agree to avoid pregnancy for at least one year after bariatric surgery.
  • Be capable of and willing to adhere to postoperative nutritional guidelines and exercise program.

    • If serious psychological diseases or addictions are present, they must be treated and stable.

Comorbidities

  • Type 2 diabetes mellitus
  • Obstructive sleep apnea
  • Idiopathic intercranial hypertension (pseudotumor cerebri)
  • Hypertension
  • Dyslipidemia
  • Metabolic Associated Steatotic Liver Disease or Metabolic Associated Steatohepatitis.
  • Venous stasis disease
  • Significant impairment quality of life
  • Intertriginous soft tissue infections
  • Stress-related urinary incontinence
  • Gastroesophageal reflux disease
  • Weight-related arthropathies that impair physical activity
  • Obesity-related psychosocial stress