Bariatric Appointment Call

Bariatric Seminar Registration

 Bariatric Surgery Accredited Center of Excellence 

Registration Form

Weight Loss Surgery Seminar Registration

* Denotes a required field
 Registrant Information
*First Name *Last Name
*Date of Birth
   mm/dd/yyyy
 Age:  Gender Female Male
*Phone # *Email
Address City
State ZIP
 Insurance Information
Name Other
Policy # Group ID
 Additional Information
Referred By Other
Other Comments
 Class Schedule for 2014
Select a class by clicking on a date below: 
South Nassau Communities Hospital
Thu, Jan 16, 14 6:00 PM Conference Room A and B
Thu, Feb 13, 14 6:00 PM Conference Room A and B
Thu, Mar 20, 14 6:00 PM Conference Room A and B
Thu, Apr 24, 14 6:00 PM Conference Room A and B
Thu, May 15, 14 6:00 PM Conference Room A and B
Thu, Jun 19, 14 6:00 PM Conference Room A and B
Thu, Jul 17, 14 6:00 PM Conference Room A and B
Thu, Aug 14, 14 6:00 PM Conference Room A and B
Thu, Sep 18, 14 6:00 PM Albert & Conference Room 2
Thu, Oct 16, 14 6:00 PM Conference Room A and B
Thu, Nov 20, 14 6:00 PM Conference Room A and B
Thu, Dec 11, 14 6:00 PM Conference Room A and B

 
 If you have any questions or need help completing this form, please call the Center for Weight and Life Management at 516-374-8631.

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