Weight Management Patient Application

Greater St. Louis Area

SSM Health Weight Management Services patient application is available for the greater St. Louis area. Complete the form to begin your weight loss journey and we will start by verifying your benefits related to weight loss.

First Name *

Last Name *

Birth Date *

Please enter as MM/DD/YYYY

Address *

City *

State *

ZIP *

Please enter a five-digit ZIP code

Phone *

Please enter phone number as XXX-XXX-XXXX

Email Address *

Height *

Weight *

Primary Care Provider *

Notes

Procedure You Are Most Interested In *

Please select your top choice

Have you had a previous weight loss surgery? *

Yes

If Revisional / Repeat surgery, please provide surgery type, physician, and surgery date

Requested Physician *

Primary Insurance Name *

Primary Insurance Member ID *

Primary Insurance Group Number *

Primary Insurance Phone Number *

Please enter phone number as XXX-XXX-XXXX

Primary Insurance Policy Holder First and Last Name *

Primary Policy Holder Employer *

Primary Policy Holder Birth Date *

Please enter as MM/DD/YYYY

Secondary Insurance Name

Secondary Insurance Member ID

Secondary Insurance Group Number

Secondary Insurance Phone Number

Please enter phone number as XXX-XXX-XXXX

Secondary Insurance Policy Holder First and Last Name

Secondary Policy Holder Employer

Secondary Insurance Policy Holder Birth Date

Please enter as MM/DD/YYYY

How did you hear about us? *

Web Search

Social Media

Word of Mouth

Physician Referral

Radio

Other

I have read the Notice of Privacy Practices. *

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Weight Management Patient Application

Greater St. Louis Area

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