Request Bariatric Information on Getting Started from McLaren Flint

*Indicates required information

Contact Information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone *

Email Address *

Height - Feet and Inches:

Weight - Pounds:

Have you had weight loss surgery in the past? *

Yes

If yes, please share which procedure you had, when you had it, and where you had it done:

Please list any chronic health conditions you have been diagnosed with, for example, diabetes, kidney disease, high blood pressure:

Insurance Plan - for example, Blue Cross, Medicaid, Medicare, etc.: *

Please let us know how we can help you and the purpose of your inquiry: *

By completing this form, you agree McLaren Health Care may contact you by phone, email or mail to answer your questions or provide referral information.

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