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New Patient Forms

Welcome and thank you for your interest in the surgical weight loss program at U.S. Bariatric! We look forward to working with you to achieve your weight loss goals.

To get started, please fill out a patient demographic form in its entirety. Once we receive these forms, we will check your bariatric insurance benefits. If you have the insurance benefit, we can then proceed with scheduling you for a consult with Dr. Marema. If you do not have insurance coverage, we will discuss your self-pay and financing options with you.

There are 3 ways to submit your form:

Please choose one of the following ways to submit your patient demographic form. You will only need to complete this process once.

Fill out demographics form online FILL OUT NEW PATIENT FORM ONLINE - You will be redirected to our online form. Once you've entered all of the required information, click "Submit" at the bottom of the page.  

Online patient demographic form Download the interactive PDF form and submit via email - If you choose this option, please click the link and download the interactive PDF to your computer. You can then fill out the form, save it, and email it back to us at krogers@usbariatric.com.

Download new patient forms Print form and email or fax it to our office - If you choose this option, please print the form, fill it out in its entirety, and fax it to our office at (904) 819-5862 or email it to krogers@usbariatric.com.

If you have already submitted your demographics form and only need to complete the medical history form, please click here.
If you have any questions, please call our office at (904) 819-5861

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