Lap Band Surgery - ObesityOff.com

Complete this form and one of our qualified counselors will contact you to discuss your case.
Name:
Occupation:
Address:
E-mail:
Phone:
Date of Birth (mm/dd/yy ):
How did you hear about us? (Pick One):
Previous diets you have followed:
When?:
Weight Lost?:	Lbs.
Weight regained?:	Lbs.
What are your worst food habits?:
Medications you are presently taking, including over the counter drugs?:
List any weight related medical conditions you are suffering from at the present time (ex: diabetes, high blood pressure, etc.):
What is your present weight?:	Lbs. Height
What is your goal weight?:	Lbs.
Timeframe for surgery?:	Immediately
	3-6 Months
	6-9 Months
Are you interested in financing options?:	Check to have info sent to you
Why is it important to you to lose weight at this time?: