"Florida Surgery & Weight Loss Center"

1
Book Your Free Consultation* This field is required.
I have a question
I want to request a Free Insurance Check
I want to request an Appointment
2
Very Good! What is Your Question?

Please submit your information, and we will get back to you shortly with an answer.
3
Very nice! Our team of experts will find out if your insurance provider covers Weight Loss Surgery.

Please submit your information, and we will get back to you shortly with next steps.
4
Excellent! Let's get you scheduled for an appointment.

Submit your information, and we will get back to you shortly with next steps.
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Contact Info* This field is required.
First Name
Last Name
Email
Phone
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How would you like us to contact you?* This field is required.
Email
Phone Call
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Question/Comment* This field is required.
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Date of Birth* This field is required.
Date
Year
Month
Day
9
Your Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
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Tuvalu
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United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Height and Weight* This field is required.
Height (ft)
Height (in)
Weight (lbs)
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Emergency Contact Info* This field is required.
Emergency Contact Name
Emergency Contact Number
Relationship to Emergency Contact
12
Drivers License / IDPlease upload a picture of your Drivers License / ID.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Do you have health insurance?* This field is required.
I have health insurance
I do not have health insurance
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No insurance? No problem!

Many of our patients are like you and do not have Weight Loss Surgery insurance benefits. Next step: hit "submit" on the next screen. We will reach out shortly to notify you about your self pay and financing options.
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Have you had Weight Loss Surgery previously?* This field is required.
YESNO
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What type of Weight Loss Surgery did you have?* This field is required.
Type of Weight Loss Surgery
Year of Surgery
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Insurance Info* This field is required.You can find all of this information on your insurance card.
Primary Insurance Holder's Name
Primary Insurance Holder's Date of Birth
Primary Insurance Holder's Employer
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Insurance Info* This field is required.You can find all of this information on your insurance card.
Insurance Company
Insurance Phone #
Member / Policy ID #
Group #
19
Insurance Card Photo (Front)This helps us, but is optional.
Drag and drop files here
Select files to upload
Min. file size1.0KB, Max. file size: 10.4MB
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Insurance Card Photo (Back)This would helps us, but is an optional.
Drag and drop files here
Select files to upload
Min. file size1.0KB, Max. file size: 10.4MB
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Additional Comments/QuestionsThis is optional
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Final Step: Hit the button "Submit" Below

You will receive an email confirmation from Florida Surgery and Weight Loss Center in the next few minutes to confirm we received your submission.

If you do not receive the confirmation message within a few minutes, please check your Junk E-mail folder just in case the confirmation email got delivered there instead of your inbox. If so, select the confirmation message and click Not Junk, which will allow future messages to get through.
Should be Empty:

Very Good! What is Your Question?

Very nice! Our team of experts will find out if your insurance provider covers Weight Loss Surgery.

Excellent! Let's get you scheduled for an appointment.

Final Step: Hit the button "Submit" Below