Are you a candidate for weight loss surgery?

1

Gender* This field is required.

Male

Female

2

Are you experiencing any of these health problems?* This field is required.

Heartburn / Acid Reflux

Sleep Apnea

Joint / Bone Issues

High Blood Pressure

Diabetes

Depression

3

Which of these is a bigger concern for you?* This field is required.

Can I afford it?

Will I keep the weight off long term?

Is Surgery right for me?

4

Which payment option describes you best?* This field is required.

Self-Pay / Financing

Private Insurance

5

Have you decided which treatment is right for you?* This field is required.

Not sure yet.

Duodenal Switch

Gastric Sleeve

Gastric Bypass

Non Surgical Weight Loss Program

6

At what stage are you in your decision-making process regarding Weight Loss Surgery?* This field is required.

Researching

Evaluating Treatments

Choosing a Doctor

Book an Initial Consult

7

Which of the Beltline Health clinics is the closest to you?* This field is required.

Atlanta

Newnan

Stockbridge

8

Height (in)

9

Weight (Ibs)

10

BMI

11

Please enter you name.* This field is required.

First Name

Last Name

12

Please enter your email and phone.* This field is required.

Please enter your email

Please enter your phone