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Doctor's Name (required)

Doctor or Best Contact Email (required)

Patient gives us permission to share information with the WLSFA (required)

Patient Contact Information (name phone and email required)

List All Self Pay Surgical Fees Needed (required)

How are self pay patient complications managed? (required)

Read Grant Program Rules Here

Click here to accept WLSFA Grant Referral Program Rules (required)

Why are you referring this patient to apply for a financial grant / gift from the WLSFA? (required)

["Please send grant application to my patient in financial need"]

Additional Comments





Who can refer patients to apply for a full grant?

Any US COE Bariatric Practice or US Plastic Surgeon that are Board Certified by the ABPS and members of the ASPS may refer one or more patient to apply for a full grant. If the patient applies and is selected for full grant funding the referring surgeon must offer to contribute the surgery and a year of follow up care, your contribution in kind.

The WLSFA funds the following: Hospital Fees, Anesthesiologist fee and Complication insurance Policy (if the Hospital does not have their own self pay complication program available) Nutritionist visits and Psychological examination fees. For bariatric patients vitamins are provided for one year.

Who can refer patients for partial grants?
Only surgeons who have contributed at least one surgery every three years can refer patients to apply for partial grants. Partial Grants are from $100 to $4000 Dollars and are funded on a case by case basis based on available funds and in order received. Partial Grants fund obstacles that can stop a patients journey to the operating room for an otherwise fully funded surgery. The WLSFA funds the following: Co-Pays, Deductibles, COBRA fees for the suddenly unemployed, other fees not covered for an otherwise insured or fully funded surgery.

Questions about the referral program? Call 415-234-9074  or email us at

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