Please complete the form below. Your information will be reviewed to determine eligibility for surgery and someone will contact you. A preliminary investigation into insured benefits for weight loss surgery may also be done as a courtesy to you.

Bariatric Health Questionnaire

Open this PDF, fill it out, and save it on your computer. When you are done, you can email it to our offices at This e-mail address is being protected from spambots. You need JavaScript enabled to view it . You can also print it out and fax it you our office at (361)574-1850.