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Consultation Request



First Name (*)

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Last Name (*)

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Email Address (*)

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Enter your phone number (*)

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Which date would you prefer? (*)

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Which time would you prefer? (*)

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Why add insurance information?

Optionally adding your insurance information will help expedite your check in process when you arrive for your scheduled consultation.


Insurance Information

Your insurance provider requires the following information for verification purposes. Please fill out the following form with the Primary Insurance Card Holder Information:

What is your relationship to the Primary Insurance Card Holder?

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Primary Card Holder's First Name

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Primary Card Holder's Last Name

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Date of Birth

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NOTE: Bariatric Solutions cannot accept coverage under Medicaid.
Insurance Provider

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Primary Card Holder's Employer

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Insurance Subscriber/Member ID

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Insurance Group/Account Number

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Insurance Provider Phone Number

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YOUR HEALTH INFORMATION:

Please answer the following questions about YOU and your HEALTH
Height (ft. in.)

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Weight (lbs.)

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Do you have any of the following health issues?









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Our insurance specialists will review your insurance information and attempt to verify your bariatric weight-loss surgery coverage. This process may take several days and require additional information from you. Our goal is to get your insurance information answered within 7 working days.




Our Offices

Decatur
2010 S Ben Merritt Drive Suite B
Decatur, TX 76234
Toll Free: 877.204.6483
Local: 940.626.4683
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Las Colinas
6750 North MacArthur Blvd.
Suite 211, Irving, TX. 75039
Toll Free: 877.204.6483
Local: 940.626.4683
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