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
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Health Self-Assessment
Does your child have any of the following conditions?



Maria's Journey

Maria was the first patient to have weight-loss surgery at Children's National. With its multidisciplinary approach, a team developed a personalized plan for the teenager.

Read More of Maria's Journey

Children's National in Your Neighborhood

A location marker

Did you know Children’s National has more than 50 locations throughout the region? Find one that’s convenient for your family.

Find a Children's Location Near You