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Department of Surgery
Bariatric Surgery


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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.

  2. The following forms may be submitted online.

    Patient Contract (45k Word doc)
    Patient Contract (30k pdf)

    Patient Advisory Form (101k Word doc)
    Patient Advisory Form (109k pdf)

    Patient Information Form (185k Word doc)
    Patient Information Form (70k pdf)

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

    Health Assessment Questionnaire (38k doc)
    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 (260k Word doc)
    Dietary Weight Loss Attempts (104k pdf)

    Exercise Weight Loss Attempts (230k Word doc)
    Exercise Weight Loss Attempts (98k pdf)

    Weight History Requirements (218k Word doc)
    Weight History Requirements (100k 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.