Thank you for your interest in Coastal Center for Obesity
The online New Patient Information Form is provided for your convenience. If you need assistance or have any questions please don't hesitate to contact us by phone or email. We are here for you and want to help make your experience with Coastal Center for Obesity a positive one.
The Staff at Coastal Center for Obesity
800 475 3383
info@coastalobesity.com
In addition to submitting this questionnaire, please send us a copy of the front and back of your insurance card. You may mail or fax this copy to us.
Please fill out all the questions as completely as possible. Plan to spend 20 to 40 minutes completing this questionnaire. When finished click the "Submit" button at the bottom of the page to process your information. Items in Red are required to be filled in.
All information included on the Pre-Operation Form will be deemed "Protected Health Information" and may be released to insurance payors, health care providers or other "Business Associates" of Coastal Center of Obesity in accordance with Title 45, Code of Federal Regulations, Section 160.103..