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Bariatric Surgery Inquiry
Weight loss surgery is a great option for someone struggling with obesity. To qualify, a person must: Have a Body Mass Index of 40 or greater, or, have a BMI of 35 or greater and a comorbidity, such as diabetes, hypertension, high cholesterol, or sleep apnea.
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First Name
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Last Name
Email
Telephone
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Date of Birth
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Your Height
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Your Weight
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Pre-existing Conditions
Arthritis
Diabetes
High Cholesterol
Hypertension
Sleep Apnea
None of the above
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Insurance Company
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Insurance Group #
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Insurance ID #
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