Northern Colorado Surgical Associates
Northern Colorado Surgical Associates
 
Home
Procedures
Bariatric Surgery
Physicians
General Information
Links
Contact Us
 
 
Our Services Include:
• Reflux Surgery
• Hernia Surgery
•

Cancer Surgery
• Gallbladder Surgery
• Colon & Rectal Surgery
• Appendectomy
• Liver & Spleen Surgery
• Lung Surgery
• Hemorrhoid Surgery
• Weight Loss Surgery
• Varicose Vein Surgery
• Breast Surgery
• Thyroid/Parathyroid Surgery
• Esophagus Surgery
• Intestinal Surgery
• Skin Cancer/Skin Lesion Surgery
  Privacy Policy | Terms of Use
  Sitemap
   
         
  Weight Loss Surgery  
Laparoscopic Banding
Gastric Bypass Surgery
Why Us?
Bariatric Guide for Patients
Weight Loss Support Groups
Weight Loss Symposiums
Light for Life Newsletter
Testimonials
Weight Loss Recipes
  PATIENT CONSULTATION >
To help assist us in determining whether you are a candidate for weight loss surgery, please complete the patient consultation information form.		  
Center for Excellence logo
Anthem logo
We encourage you post a comment on ObesityHelp.Com about your experience with NCSA, your doctor and or hospital stay.
 
PATIENT CONSULTATION

To help assist us in determining whether you are a candidate for weight loss surgery, please complete the following form, and a nurse will return your inquiry.

    
 
   
First name:
 *
Last name:
 *
Address:
 *
City:
 *
State:
 *
Zip:
 *
Phone number:
 *
Email address:
 *
Date of Birth:
 *
Height:
 *
Weight:
 *
Insurance Provider:
 *
Group #:
 *
ID #:
 *
Insurance Phone Number:
 *
Have you had weight loss surgery in the past?*
Yes  No  
If yes, what type of surgery?
 
Have you had stomach, esophagus or spleen surgery?*
Yes  No  
   
Have you had connective tissue disease (like lupus)?*
Yes  No  
   

* I am Interested in:


 Lap Band
Gastric Bypass
Revisional Surgery
Where did you hear about us?
  *required