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To Contact By Phone: (317) 814-4590

When using this form to contact the office, we'll gather your information so we can schedule an appointment for you, obtain the correct type of referral, send pertinent information regarding types of surgeries or have a representative at the bariatric center call you to make an appointment for a consultation.

Name:

Phone:

E-Mail:

Address:

City:

State/Zip:
  
Primary Care Physician:


What surgery are you interested in?
GASTRIC BYPASS
REVISION GASTRIC BYPASS
HERNIAS, ANY TYPE
BREAST, EXCISION OR BIOPSY
GALLBLADDER
COLON OR RECTAL
TOENAIL, CYST OR LESION
HEMORRHOID
HYSTERECTOMY, PARTIAL OR TOTAL
GENERAL GASTRIC PROCEDURES
PORTA CATH PLACEMENT
OTHER BIOPSIES

What is your age range?
18-25
26-36
37-47
OVER 48 YEARS

What type of insurance do you have?
COMMERCIAL
MEDICARE PRIMARY
MEDICAID PRIMARY

Who may we thank for recommending Dr. Huse?