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Pre-Registration

Before you are able to fill out the pre-registration form, we must determine your Body Mass Index to see if you qualify.

Your Weight:

lbs.

Your Height:

ft. and in.

First Name
Middle Name
Last Name
Gender
 Female   Male
Email
Street Address 1
Street Address 2
City
State
Zipcode
Phone Number ()-
Lifestyle activity level
Co-Morbidity
 Cancer  High Cholesterol  Prediabetes
 Depression  Gallbladder Disease  Stress Urinary Incontinence
 Female Reproductive Health  Gastric Reflux  Type 2 Diabetes
 Heart Disease  Obstructive Sleep Apnea  High Blood Pressure
 Osteoarthritis  Stroke  Other
 Breathing Difficulties  Joint Problems
Do you know if your insurance provider covers bariatric surgery?
 Yes   No

Primary Insurance:
Insurance ID #:

Self Pay      I Need Help

Medical Doctor:

Free bariatric seminars are mandatory and the first step into the program. Day and evening seminars are offered in an attempt to meet the needs of anyone interested.

All Baratric Seminars are held at:
The Bariatric Center
1602 W. Northfield Blvd., Suite 503
Murfreesboro, TN 37129
(get directions)

Please choose a class from the listing that you would like to attend