Bariatric Surgery Consultation Request

This form is for families who are interested in learning more about our weight-loss surgery program for adolescents. The purpose of this form is to give our staff some information to move forward with you and your child in your journey to better health. Parents or guardians must complete this form and the child should be 12 years or older.

Please expect a response from one of our staff members in 3 business days.

Intake Information
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Relationship to Patient:
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Other Information
Reason for contact:


Health Self-Assessment
Is your child currently at his/her highest weight?
Does your child have any of the following conditions?




Do you have a family history of any of the following conditions?