Seminar Registration

Seminar Registration

The first step in Changing your life is to attend a free informational seminar.

At the seminar, you will learn the facts about weight-loss surgery, how this can be an effective treatment for you, how surgery is performed, associated risks and complications and what kind of weight loss to expect. You will also learn what your life will be like after surgery, and how to effectively use your band as a tool to change your life.

To register for one of our lap-band seminars, please complete the following information. Indicate which seminar you will be attending.

Seminars are held at: Lakeshore Surgery Center 7200 N. Western Ave. Chicago, IL 60645 773-465-SLIM (7546) 877-6-LAPBAND Monday evenings at 6:00 P.M.

Seminar Dates: August 25 September 22 October 20 November 24 December 15

* = Required Field

First Name *		Last Name *
Email *
Street Address
City *	State * AL AK AZ AR CA CO CT DE DC FL GA HA ID IL IN IA KA KE LQ ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip
Height *	3 4 5 6 7 Ft. 0 1 2 3 4 5 6 7 8 9 10 11 In.	Weight (lbs.) *
Home Phone		Cell Phone
Best # to contact	Home     Cell	Can we leave a message?	Yes     No
How did you hear about us?
Do you have insurance?	Yes     No
What is your insurance?
Which date will you attend? *	August 25, 2008, 6:00 pm September 22, 2008, 6:00 pm October 20, 2008, 6:00 pm November 24, 2008, 6:00 pm December 15, 2008, 6:00 pm
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