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PLEASE TELL THE PATIENT: "You should have just received a text message letting you know that it takes us 1 to 2 business days to check your insurance. We'll text you as soon as we hear back from your insurance company." STAFF REMINDER: Before submitting a new form, please refresh this page.

Request An Appointment

What type of patient is this?

Request Insurance Information from Patient Schedule Now Authorization / Referral Received Only Add Patient to Hive (No Auto-Texts Sent to Patient)

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First Name

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Last Name

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Your body mass index (BMI) only qualifies you for the Gastric Balloon procedure. Please change your procedure selection to “Gastric Balloon” if you would like to proceed. Change to Gastric Balloon to proceed

If for some reason your insurance does NOT cover the procedure, how would you like to pay?

Have you had weight loss surgery before?

Yes No Select any one option.

Cell Phone (for text messages)

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Check the box to agree to communicate via text message You must opt-in to text messages to proceed.