Bariatric Online Information Session

 

Welcome to the online bariatric information session. The session is broken into four parts. An initial 10 minute video followed by required questions and then another 24 minute video followed by required questions.

To start your online session please complete the below registration form.

 
First Name:*
 
Middle Name:
 
Last Name:*
 
 
Street Address:*
 
City:*
 
State:*
 
Zip Code:*
 
 
Preferred Phone Number:*
 
Email Address:*
 
 
I would like to have all paperwork emailed to me at the above email address:
 
Date of Birth:*
(MM/DD/YYYY)
 
Gender:
 
Primary MD:
 
Phone:
 
 
Insurance Information:
Insurance Company:
 
If applicable, please complete as our office will verify your insurance coverage prior to your visit.
 
I am interested in having:



 
I am currently being treated for or have a history of (check all that apply):

 
The Tanita Scale uses a small electrical current to measure your body composition.
Please let us know if:
You are pregnant:
Have a pacemaker:
 
How did you find out about our program? (Check all that apply):




 
Referring Physician:
 
 
I am interested in the bariatric program. Therefore, I authorize the release of any information to determine eligibility, benefits, co-payments or any out-of-pocket expenses. I also give permission for any insurance company to inform RSF Bariatric and Metabolic Services of the reasonable and customary reimbursements for my surgical procedure. RSF Bariatric and Metabolic Services has my permission to send me future information about their services.
 
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