Bariatric Seminar Online Registration

Select a seminar:*
Name*
First Last
Date of Birth (mm/dd/yyyy)*
Date Format: MM slash DD slash YYYY
City*
Phone*
Email*
Weight*
Feet*
Inches*
Required:*
- I understand and agree that, based on my preferences, my information will be shared with an independent physician practice that will contact me with more information about whether I am an appropriate weight-loss candidate.
Required:*
- While Covenant Health’s websites are secured to very high standards, your information may be visible or accessible during transmission over the internet depending on the configuration of the device and network you are using to access this website. It is recommended you use a computer that is running a current and fully updated operating system and reputable anti-virus/internet security software that receives automatic updates. You should never exchange sensitive information when connected to an unsecured, public Wi-Fi network.
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