Application Request Form

If you have any questions about this form, please email info@wlsfa.org BEFORE filling this form out.

Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bariatric Surgeon Information
In order to proceed with the application process, your bariatric surgeon MUST have already agreed to donate his/her time for your weight loss surgery. If you have not spoken to your bariatric surgeon about donating his/her time, please speak to them BEFORE proceeding.
Are you a patient of a “Center of Excellence” bariatric surgeon and practice?*
- Yes
- No
- I do not know
Has your surgeon agreed to donate his/her time for your bariatric surgery?*
- Yes
- No
Have you been medically approved for bariatric surgery?*
- Yes
- No
Are you exempt from coverage for bariatric surgery by your insurance or have been denied coverage of bariatric surgery or have no medical insurance?*
- Yes
- No
Surgeon Name*
First Last
Surgeon Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Surgeon Phone*
Name
This field is for validation purposes and should be left unchanged.

Bariatric Surgeon Information