Can I complete my application online?

Optional online registration

Would you like to get started now? You can download and complete our application forms before your consolation.

  1. Watch our presentation here.

    Print and sign the Certificate of Completion (pdf).

  2. The following forms may be submitted online.

    Patient Contract (pdf)
    Patient Advisory Form (pdf)
    Patient Information Form (pdf)

  3. The Health Assessment Questionnaire may be mailed or faxed to our office.

    Health Assessment Questionnaire (pdf)

    Fax to:
    ECU Bariatric Surgery at 252-744-3469

    or Mail to:
    ECU Bariatric Surgery Office
    600 Moye Blvd.
    PCMH TA 201
    Greenville, NC 27834

  4. Fill out and bring these forms to your consultation.

    Dietary Weight Loss Attempts (pdf)
    Exercise Weight Loss Attempts (pdf)
    Weight History Requirements (pdf)

We look forward to seeing you for your consultation. Our office is at 517 Moye Boulevard. You can reach us at 252-744-2018 or by email at weightlosssurgery@ecu.edu.