Request a Weight-Loss Consultation

Thank you for your interest in scheduling a weight-loss consultation with one of our physicians. Please complete the online form below and someone from our office will contact you to arrange an appointment.

In the interim, please sign-up for a free virtual seminar to learn more about our weight-loss surgery options.

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Name Date of Birth Your Weight Your Height Do you take any medications or use oxygen for any health conditions Yes No Street Address City State/Province Postal Code Email Phone Insurance Insurance Company Name (if not listed above) Insurance Policy Number Preferred Physician Brett Cohen, MD Jeremy Gallego Eckstein, MD Emil Matei, DO Joseph W Melendez-Davidson, MD No preference

Verification of insurance Benefits

I authorize verification of my insurance benefits by Memorial Weight-Loss Surgery Program, and understand that it is my responsibility also to contact my insurance company to verify coverage and benefits.

Representative Contact Authorization

I authorize a representative from Memorial Weight-Loss Surgery Program to contact me regarding my online registration.

Request a Weight-Loss Consultation

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Request a Weight-Loss Consultation

Patient- and Family-Centered Care

Start Your Weight Loss Journey