Military Bariatric Surgery Waiver Request
Submit your request and acknowledge the waiver for bariatric surgery as a military personnel.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Military Branch
*
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Other
Rank
*
Service Number (Last 4 Digits Only)
*
Type of Bariatric Surgery Requested
*
Gastric Bypass
Sleeve Gastrectomy
Adjustable Gastric Band
Other
Requested Surgery Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical History (including prior surgeries, current medical conditions, and medications)
*
Reason for Requesting Bariatric Surgery
*
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
Submit Request
Submit Request
Should be Empty: