Vitamin Assistance Application
At Bariatric Complete, we believe that everyone deserves access essential vitamin supplements. That's why we're committed to helping you find affordable options. Please fill out the application to discover how you can receive free or discounted supplements tailored to your needs. Your health is our top priority!

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

What type of bariatric surgery have you had?

Marital Status

Current Employer

Spouse Employer (if applicable)

Are you on a vitamin supplement program with your physician?

Yes

Do you have any children under 18 living with you?

If Yes to the previous question how many children do you have?

Do you receive child support or alimony?

Does anyone in your house receive disability/SSI?

What is your monthly household income?

Does anyone in your household receive government funding for medical, house and/or food stamps? If yes, how much for each government fund.

By signing I verify that all of the information listed on this document is the full and honest truth and nothing is falsified. I understand that if supplement support is given and then it is discovered that the information provided was falsified or incorrectly expressed, you will be responsible to pay the full payment of all product distributed going back to the first shipment. I understand that this appliance is not a guarantee of free or reduced priced supplements.

Signature

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Please upload proof of income, any financial assistance you are receiving, or any additional documents that support your need for vitamin assistance. Thank you