To learn more about our weight loss surgery program, please
complete the following form. Our Bariatric Nurse Navigator will
contact you to answer any questions you may have about the program
and schedule an appointment or consultation.
Please Note: This form will be
used by Lourdes and the Lourdes Bariatric Nurse Navigator to gather
information about you for our bariatric weight loss program. Under
no circumstance will Lourdes voluntarily disclose your personal
information to any party without your specific consent or as
requested by law. For more information about our privacy practices,
please read our Joint Notice of
All fields are required, except the BMI field.