Weight Loss Surgery Program at Lourdes

Tell Us About Yourself

To learn more about our weight loss surgery program, please complete the following form. Our Bariatric Nurse Navigator will contact you to answer any questions you may have about the program and schedule an appointment or consultation.

Please Note: This form will be used by Lourdes and the Lourdes Bariatric Nurse Navigator to gather information about you for our bariatric weight loss program. Under no circumstance will Lourdes voluntarily disclose your personal information to any party without your specific consent or as requested by law. For more information about our privacy practices, please read our Joint Notice of Privacy Practices.
All fields are required, except the BMI field.
If known, please enter your BMI above.
LOURDES Hospital | 169 Riverside Drive • Binghamton, NY 13905 | Phone: 607-798-5111 / Directory | Email: