Weight Loss Seminars

* First Name

* Last Name

* Telephone

* Email

* Address 1

Address 2

* City/Town

* State

* Zip Code

* Preferred Treatment Location North: INTEGRIS Health Baptist Medical Center South: INTEGRIS Health Southwest Medical Center

Preferred Physicians at North North: Dr. Le

Preferred Physicians at South South: Dr. Farukhi

* Last 4 Digits of SSN

* Date of Birth

* Estimated Height

* Estimated Weight

* Insurance Company Name

Last 4 Digits of SSN of Insurance Holder (if different than yours)

* Insurance Customer Support Telephone

* Insurance Subscriber Number

* Insurance Group Number

Secondary Insurance Company Name

Secondary Insurance Company Support Telephone

Secondary Insurance Subscriber Number

Secondary Insurance Group Number

* Have you had a previous bariatric surgical procedure? Yes No

* If Yes, please list type of surgery and reason for needing a bariatric surgeon consultation post-surgery

* Is this procedure for medical weight loss or surgical weight loss? Medical Weight Loss Surgical Weight Loss

How Did You Find Us? My Doctor INTEGRIS Health Website Web Search (Google) TV Radio Print Friend Other

If Other, please tell us how

* INTEGRIS Health may contact me

Online Weight Loss Seminar