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Online Weight Loss Seminar

Home » Health Care Services » Bariatric & Weight Loss Surgery » Online Weight Loss Seminar

In This Section

Services

1Section 1

2Section 2

3Section 3

4Section 4

5Review

Section 1: Demographics

Name

First Last

Email(Required)

Enter Email Confirm Email

Date of Birth

Month

Day

Year

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Section 2: Online Seminar Video

Read the below document. After you have fully read it move on to Section 3.

Consent(Required)

I have fully read the online seminar from above and I am ready to see if I qualify.

Section 3: Insurance

Please fill out this form to see if you qualify, and we will begin the process to see if you are qualified.

Type of Insurance

Medicare

Medicaid

Commercial

Other

What is the name of your insurance company?(Required)

Policy ID #(Required)

Policyholder's Name(Required)

Policyholder's Date of Birth(Required)

Month

Day

Year

Benefits/Customer Service Phone #(Required)

Section Break

Patient's Height

Patient's Approx. Current Weight

Patient's Primary Care Provider's Name

Patient's Primary Care Provider's Phone #

Patient's Interest

Select All

Medication Weight Management ONLY

Gastric Sleeve

Gastric Bypass

Revision Surgery

Skin Removal

Undecided/Other

Step 4

Please review the below information for accuracy.

{all_fields}

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Ephraim McDowell Health
217 South Third Street
Danville, KY 40422

Phone: (859) 239-1000

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