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  1. First Name*
    Your first name is required.
  2. Last Name*
    Your last name is required.
  3. Email Address*
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  4. Phone Number*
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  5. Which date would you prefer?*
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  6. Which time would you prefer?*
    Preferred time is required. Use morning/afternoon/evening if you are not sure of an exact time.

  8. Why add insurance information?

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

  9. 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:

  10. What is your relationship to the primary insurance card holder?
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  11. Primary Card Holder's First Name
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  12. Primary Card Holder's Last Name
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  13. Date of Birth
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  14. NOTE: Bariatric Solutions cannot accept coverage under Medicaid.

  15. Insurance Provider
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  16. Primary Card Holder's Employer
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  17. Insurance Subscriber/Member ID
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  18. Insurance Group/Account Number
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  19. Insurance Provider Phone Number
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  20. Health Information

    Please answer the following questions about YOU and your HEALTH.

  21. Height (ft. in.)
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  22. Weight (lbs.)
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  23. Do you have any of these health issues?









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  25. 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.