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First Name: Last Name: Address: Phone #: Alternate Phone #:	City: State: Zip: Email:

Insurance Company: Insured's name: Date of Birth: Customer Service Phone Number (Usually located on the back of your insurance card.)	Insured's employer: Member Policy #: Group #:

Do you have any of the following obesity-related diseases?
Diabetes Hypertension	Sleep Apnea High Cholesterol
What type of weight loss program are you interested in?
Gastric Banding Roux-n-y Bypass Gastric Sleeve Duodenal Switch	Revisional Procedure ROSE Procedure POSE Procedure Non-Surgical Weight Loss Program

Body Mass Index (BMI) is the measurement that will help determine if you're a candidate for this surgery. Gender Male Female Height ft. in. Weight: lbs. Age

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Contact Us: Info@whyweight.com

Surgical Specialists of Louisiana can only quote benefits and does not guarantee insurance payment of eligibility. In addition, we encourage all patients to check your member booklet or call your insurance company. Your human resource department is required to issue you a plan booklet which discloses all your covered and non-covered benefits.

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