Baptist Hospital East : Weight-loss seminar registration form

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Baptist Hospital East now offers weight-loss surgery using the LAP-BAND® and REALIZE(TM) band. This type of surgery has helped many seriously overweight individuals achieve and maintain significant long-term weight loss.

Please provide your name, complete address and phone number to receive a patient information packet prior to the seminar; those registrations received too close to the seminar date for mailing will be sent by email.

Please note: All fields marked with an asterisk (*) are required.

* First name:
* Last name:
* Address:
* City:
* State:
* Zip:
* Phone:
E-mail address:
* Seminar date:
* How many people (incl. yourself) will attend?:
* How did you hear about the program?:
If you selected "other," please tell us where: