Registration Form for Free Weight Loss Surgery Information Session

We look forward to seeing you at one of our free weight loss surgery information sessions to discuss gastric bypass and LapBand procedures. To register online for our surgical weight loss information session, please fill out the form below. Dates of sessions are listed below this form for your convenience.

Click here to download an application to our program
Applicants are required to attend an information session, but you may bring a completed application with you to the session. Just download the above application, print it and bring it with you to an informational session. For your convenience, we will also make a copy of your insurance card at the session to begin initial work on that segment of the process.

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* Required Fields

First Name * Last Name *

Address
*

City
* State *
Zip Code *

Email Address

Phone Number

Session Date You'll Be Attending

How Many People Will Be Attending?
*

How Did You Hear About the Session?
*

If you selected other, please indicate how you heard about the session.

If a physician referred you, what is the physician's name?

Who is your insurance carrier?

Who is your employer?

Which Surgery Are You Considering?

Check here if you do not want to Portsmouth Regional Hospital or Parkland Medical Center to communicate with you via email about hospital events or programs.

General Internet communication is inherently not secure. For this reason, we highly recommend that data considered confidential or private in nature not be submitted on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.)

Parkland Medical Center

One Parkland Drive
Derry, NH 03038

Telephone: (603) 432-1500

You May Also Visit Us At http://www.parklandmedicalcenter.com

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