Thank you for considering the Vanderbilt Center for Surgical Weight Loss. Want more information about who qualifies for surgical weight loss or the procedures we perform? We welcome your questions and can give you better answers if you tell us a little about yourself. If weight loss surgery is right for you, we will design a treatment plan for your needs. Any information you provide will be kept confidential.

All information fields must be completed or the form will return an error message when submitted.

Last Name:

First Name:

Street Address /Apt

City:

State:

Zip Code:

Area Code

Phone

Email:

Location and date of seminar you plan to attend:

Your body mass index (BMI) will help determine if you should consider surgical weight loss.

Gender:

MaleFemale

Height: Feet

and Inches

Weight (pounds):

Age:

Your health insurance provider may consider weight loss surgery a covered benefit. Let us know the name of your insurance provider. Please include the telephone number and area code. If you are not insured, please let us know.

Insurance Provider Information

How long have you been considering having weight loss surgery?

Less than a year

About one year

About two years

Longer than two years

Do you have any health-related conditions that you feel may be influenced by your weight? If so, provide a brief description of them here. Any information you provide remains confidential.

Have you talked to your doctor about weight loss surgery?

Yes

No

How did you hear about the Vanderbilt Center for Surgical Weight Loss?

From a friend

From my doctor.

From a member of my family.

From the newspaper.

From a radio advertisement.

From the Vanderbilt Center for Surgical Weight Loss web site.

Not referred.

If you have additional comments or questions about weight loss surgery or the Vanderbilt Center for Surgical Weight Loss, please add them here and a representative for our Center will contact you. Please indicate whether telephone or e-mail contact is preferred.

Please press the Submit button only once.