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Bariatric Patient Information Form

Thank you for being interested in Western Surgical’s weight loss program. Please fill out the form below for us to best serve you. If you have questions, please call us at (775) 326-9152.

I have watched Western Surgical's online seminar(Required)

Yes

No

Click here to watch the online bariatric seminar.

Do you have a surgeon preference?

John Ganser, MD

Lars Webb, MD

No preference

Your Name(Required)

First Middle Last

Gender(Required)

Female

Male

Nonbinary

Height(Required)

Weight(Required)

DOB(Required)

BMI

Marital Status

Ethnicity

Current Diagnoses

Select all that apply. If your diagnosis is not mentioned, please fill out the other diagnoses section.

Sleep Apnea

Type 2 Diabetes

GERD

High Blood Pressure

Heart Disease

Other Diagnoses

How did you hear about us?(Required)

Friend or family member

Search Engine (Google, Yahoo, etc)

Social Media

Physician referral

Other

Yes, I would like to receive marketing communications.(Required)

Yes

No

Contact Information

Your Address

Street Address Address Line 2 City State ZIP Code

Your Phone(Required)

Your Email Address(Required)

Email Address Confirm Email Address

Do you have medical insurance?(Required)

Yes

No

Primary Physician

Preferred Pharmacy

Primary Insurance

Member ID #

Policy Holder If Not Patient

Relationship to Patient

Policy Holder DOB

Employer

Occupation

Group Plan Number

Customer Service Phone Number

Do you have secondary medical insurance?(Required)

Yes

No

Secondary Insurance (If Applicable)