I’m Ready for the Next Step

You’ve taken your first step to learning about bariatric surgery.

After submitting this form, our Bariatric Specialist will follow up with you to discuss next steps—including insurance verification, medical history, and scheduling a consultation with a surgeon.

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Full Name (Last, First)

Phone

Date of Birth

Height ft

Weight lbs

Have you been diagnosed with the following?

Hypertension

Type II Diabetes

Sleep Apnea

Insurance Company

Other

Insurance Member ID #

Insurance Provider Customer Service Phone Number

Is the name on the insurance card the same as above?

Name on Card

Relationship

Date of Birth

Preferred Location

First Available

Saint Luke’s Hospital of Kansas City

Saint Luke’s East Hospital

Saint Luke’s North Hospital

Saint Luke’s South Hospital

Preferred communication method (phone/email)