Request a Consultation

Request an appointment by filling out the form below.
1

Tell us how to get in touch with you

First Name
Last Name
Address
City
State
Zip Code
Phone Number
Alternate Phone Number
Email
Confirm Email
2

Tell us your preferred appointment time

Please select 3 possible days and times when you are available so that we can best schedule your appointment.
1st Choice
2nd Choice
3nd Choice
3

What type of procedure are you interested in?

Gastric Bypass
LAP-BAND
Realize Band
Gastric Sleeve
Revisonal Surgery
Other
4

Insurance Information

Insurance Company
Insured's Employer
Member Policy Number
Group Number
Insured's First Name
Insured's Last Name
Date of Birth
Customer Service Phone Number

(Usually located on the back of your insurance card)
5

Help us determing your weight loss needs

Body Mass Index (BMI) is the measurement that will help determine if you're a candidate for this surgery.
Gender
Male
Female
Weight
lbs.
Height
ft.
in.
Age
A How did you hear about us?

Cities we serve:

  • Trumbull
  • Bridgeport
  • Milford
  • New London
  • Stamford
  • Fairfield
  • Waterbury
  • New Haven
  • Southbury
  • Danbury
  • Greenwich