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
Are you a patient of a “Center of Excellence” bariatric surgeon and practice?*
- Yes
- No
- I do not know
Have you been referred to the WLSFA by a surgeon to apply for a grant AND is willing to donate your surgery through the Weight Loss Surgery Foundation of America.*
- 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.