Bariatric Surgery Center
TAKE THE NEXT STEP!

Complete this form and we will contact you within 10 days.

Fields marked with a red asterisk (*) are required.

First Name *



Last Name *



Email *



Phone *



Date of Birth *



I certify that all the information below is true. (Why do we ask this?)

I am between 21 and 75 years of age. *

My BMI is between 35 and 65. *

I am nicotine-free, or willing to make the lifelong commitment to quit. *

I am marijuana-free, or willing to make the lifelong commitment to quit. *

I am interested in having either gastric bypass or sleeve gastrectomy surgery. *

I have contacted my insurance provider about bariatric surgery coverage. *

BMI CALCULATOR
HEIGHT

Feet

Inches

WEIGHT

lbs




  • RESULTS
CONTACT US

Interested in surgery, but don't quite meet the criteria in the form? It's OK! Give us a call at 503-814-5286. We'd be happy to discuss your situation and other weight-loss options.

Learn more about eligibility for bariatric surgery at Salem Health.

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