Weight-loss Seminar Registration Form

Weight loss surgeries are available at Baptist Hospital East and Baptist Eastpoint

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 e-mail.

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

Registrant Information

* Name:
* Address:
* City:	* State: * Zip:
*Home Phone:
*Cell Phone:
* Email:
* Gender:	Male Female
* Date of Birth:	(MM/DD/YYYY)
* Height:
* Weight:

Seminar Information

* Seminar Date:
Are you rescheduling from another date?	No Yes
How many people (incl. yourself) will attend?:

Additional Information

* How did you hear about this seminar?
Please Provide Physician's Full Name:	First Name: Last Name:
Please tell how you heard of this seminar: