Intragastric Balloon Information Session

 

Welcome to the online intragastric balloon information session. To start your online session please complete the registration form below. Then a 3-minute video will begin. 

 
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 intragastric balloon 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 the Roper St. Francis Bariatric Surgery and Medical Weight Loss program of the reasonable and customary reimbursements for my surgical procedure. Roper St. Francis Bariatric Surgery and Medical Weight Loss has my permission to send me future information about their services.
 

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