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Registration for Webinar
*** Please read ALL the information on this page carefully and to its full extent. Any information you need to know about our upcoming webinars will be on this page or the next one the prompts up, including: dates and times, link information, and documentation that needs to be sent to us before being able to schedule an appointment. Thank you, we look forward to meeting you all!***
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Email *
Last Name *
First Name *
Date of Birth *
Phone Number *
Height/Weight *
Insurance Name (Please specify the plan type. e.g. Community Plan, UMR, Medicare) *
Member ID *
Provider Number (Usually found on the back of your insurance card, needed for verification purposes) *
Are you the Primary Insured *
Please complete the following: 1. Email a copy of your Driver's License along with your Insurance ID card (front and back) to (This is to obtain bariatric benefits from your insurance.)  2. Attach a "selfie" photo for your chart. 

If we do not receive this information you will not be sent a link to attend the webinar. Please make sure everything is complete after you register. The New Patient Registration forms will be sent to you after attending the Webinar. Thank you!
Thank You
**IMPORTANT**: After submitting this form, please read the following page that pops up for more information on dates and times of the upcoming webinars.
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