Schedule Appointment Request

To schedule your appointment with one of our surgeons, please complete the form below. Once we receive your request someone in our office will contact you to collect your insurance information, discuss availability and confirm your appointment.

During this consultation a thorough medical evaluation will be performed and any appropriate tests will be ordered so the doctor can determine which procedure might be right for you. *NOTE, there is no obligation to schedule surgery from here. This is an initial consult to see if surgery is an option for you. Physician office visits will be billed to insurance at the time of service.

Your Information

    First Name*

    Last Name*

    Phone Number*

    Email Address*

    Health Information



    Have you had previous weight loss surgery?

    If yes, what kind of surgery did you have?

    Medical Problems. Check all that apply.

    Type of Consultation

    Preferred Method of Contact

    How did you hear about us?

    Payment Method

    By submitting this form you agree to receive email marketing messages and to receive automated text messages (e.g. schedule appointment) from Nicholson Clinic at the number used in the form. Reply ‘STOP’ to cancel. Msg. frequency varies. Msg. & data rates may apply. View Terms of Use and Privacy Policy.