Bariatric Service Information Session Registration

Please use this form to register for an upcoming Bariatric Services Information session. All fields are required.
Instructions:
1. Please read these instructions completely before attempting to register for our on-line or in-person seminar.
2. Have your health insurance card in front of you as we will need accurate information in order to get you started in a timely fashion.
3. Give yourself at least an hour of uninterrupted time to completely register and view all sections of the seminar as it will time out and require to start the process over.
4. Please do not attempt this on a cell phone or tablet as they may not be powerful enough to complete the seminar.

Name: *

First

Middle

Last
Address: *
City: *
State: *
Zip Code: *
Contact Phone Number: *
 - 
###
 - 
###

####
Email: *

If you donít have an email address, please type N/A
Date of birth: *
 
mm/dd/yyyy
Preferred Language:
Gender: *
Female
Male
Employment: (Select from below) *
Disabled
Part Time
Self Employed
Homemaker
Student
Retired
Unemployed
Not Specified
Full Time
On Active Military Duty
How did you hear about our information session? *
Not Specified
Physician
Support Group
Newspaper Ad
News Story
Advertisement
Web
Cleveland Clinic Health Essentials Website
Cleveland Clinic Bariatric and Metabolic Institute Website
Google Search
Clickable Online Banner Ad
Facebook
Social Media
Other