* Input Required

1) Name: *

2) Address:*

3) City:*

4) State : *

5) Zip Code: *

6) Phone Number: *

7) Occupation:

8) Email:*

9) Date of Birth: (mm/dd/yy)

10) Please list any medications you are currently taking:

11) Please list all present medical conditions:

12) Please list all previous surgeries:

13) What is your present weight:

14) What is your height?

15) Age: *

16) Time frame for surgery: *

17) Are you interested in financing? (yes, no, maybe)

18) Please list any questions or concerns here:

* Input Required

We at weighless4life.org have learned,
first hand, how to locate the best doctor,
how to pay for the procedure,
how to do the international traveling,
how to work with the band in the initial liquid diet phase,
how to tell when an adjustment is needed,
how to deal with any discomforts,
how to choose foods wisely and most of all.....

HOW TO CHANGE THE THINKING HABITS
WHICH ARE A CONSTANT ENEMY OF
OUR NEW-FOUND FREEDOM FROM OBESITY.

THE BIGGEST HELP TO US, AS WE TRAVEL
THIS NEW HIGHWAY, IS THE SUPPORT,
ENCOURAGEMENT AND FELLOWSHIP
OF OTHER BANDED SISTERS AND BROTHERS.

Sanchez-Bandsters-Patient-Support