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Bariatric Surgery

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Patient Form

Please fill out the form below for more information on our program, and we will call you within 1 week. Please call 435-637-4590 to speak with us today.

Bariatric Patient Form

Full Name

Phone Number

Height

Weight

Have you watched the online Bariatric Orientation Video?YesNo

Are you interested in surgical or non-surgical weight loss?Non-SurgicalSurgical

Who is your Primary Care Provider?

Have you ever been diagnosed with the following?DiabetesHeart DiseaseHigh Blood PressureHigh CholesterolSleep Apnea

Do you have health care insurance?YesNo

If Yes, what is your health care insurance?

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300 North Hospital Drive
Price, UT 84501

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