You are registering for the following seminar:

Wednesday, July 23rd
7:00 p.m.
Specialty Surgery Center of Ft. Worth
1717 Precinct Line Road
Hurst, TX 76054

Name:
E-Mail:
Phone:
Approx. Weight:
Height:
Total People Attending:
Describe Those Attending: (check all that apply): Self
Spouse/Friend
Spouse/Friend interested in the Lap-Band
How Did You Hear About Us?

 
©2006-2008 Metroplex LapBand