Online Bariatric Surgery
Information Session

The Online Bariatric Surgery Information Session, with Dr. Tiesenga, will begin once you submit this completed form.

Insurance Information
The following information is optional, but will speed up the process.

Help us determine your weight loss needs.
Body Mass Index (BMI) is the measurement that will help determine if you are a candidate for this surgery.


Yes, I am interested in learning more about surgical weight loss options. By checking this box, I authorize The Chicago Center for Bariatric Surgery & Medical Weight Loss to contact me to obtain the health information required to begin the process.