• 1700 SW 7th Street, Topeka, Kansas 66606-1690
  • 785-295-8000

Bariatrics Paperwork

Thanks for watching the bariatrics seminar and for taking the quiz. Review the answers below and fill out the form to start your weight loss journey with St. Francis Health.

  1. Body Mass Index
  2. Laparoscopic adjustable gastric banding
  3. All of the above

NOTE FROM MONICA: the form below is used as a layout example only for you to discuss with providers. Please do not fill it out.

To ensure proper processing, please submit this form at least two business days (48 hours) prior to your scheduled procedure or test. If you have any questions, please call 303-272-0999 for hospital pre-registration information.

Have you been a patient at Good Samaritan Medical Center in the past?
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Patient Information:
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Emergency Contact:
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Insurance Information - Please bring your insurance card and photo ID with you.
Is insurance through an employer other than Patient's current employer?

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Secondary Insurance information OR maternity patients whose baby will be covered by insurance other than mother.
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Procedure Information:
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Maternity Patients Only:
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