Request a Weight Loss Surgery 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 weight-loss surgery seminar to learn more about our weight-loss surgery options.

Name Date of Birth Your Weight Your Height Do you take any medications or use oxygen for any health conditions

Yes

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.

Contact us today to take the first step on your weight loss journey.

Call Us: 954-276-1400 Request a consultation

Daughter learning how to assist her mother during a Family In Training (FIT) Program session at Memorial Regional South.

Patient and Family Centered Care

We treat patients and family members as partners in healthcare.

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