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Dr. David Kim Kim Bariatric Institute

DFW Internal Team Intake Form

Please use the form fields below for patient calls and include your name in the first field.

Please fill out the information below to have a member of our team contact you.

Personal Information

Please fill out all information completely.


Please fill in all BMI fields.

Medical Problems:

Would You Like a Free Insurance Check?

*We offer low-interest, affordable monthly payments for self-pay patients who qualify.

DFW Bariatric Institute wants to make this process easy for you.
Please fill out the information below so that we can make all necessary arrangements to help get your journey started.

Insurance Information

Please fill out all information.

Note: The following insurance providers are not accepted at this time:

  • Molina Healthcare (Medicaid)
  • Amerigroup (Medicaid)
  • Golden Rule
  • THR
  • JPS
  • HCA
  • Tricare
  • Medicare
  • Medicaid
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