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Seminar Registration
Fields with an asterisk (
*
) are required.
Seminar Details
Date and Time of Seminar:
July 20, 2013, 10:00 AM - 11:00 AM
August 1, 2013, 6:00 PM - 7:00 PM
August 17, 2013, 10:00 PM - 11:00 AM
September 5, 2013, 6:00 PM - 7:00 PM
September 21, 2013, 10:00 AM - 11:00 AM
October 3, 2013, 6:00 PM - 7:00 PM
October 19, 2013, 10:00 AM - 11:00 AM
November 7, 2013, 6:00 PM - 7:00 PM
November 16, 2013, 10:00 AM - 11:00 AM
December 5, 2013, 6:00 PM - 7:00 PM
December 21, 2013, 10:00 AM - 11:00 AM
Title:
Free Weight Loss Surgery Seminar at Baptist Hospital East
Where
Baptist Hospital East Education Center (Room 2AB) at 4000 Kresge Way, Louisville, KY 40207
Patient Information
Date of Birth:
*
-Month-
January
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-Year-
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Height
*
Feet
Inches
Weight
*
Pounds
First Name:
*
Last Name:
*
Gender
*
--select a gender--
Male
Female
Contact Information
Address 1:
*
Address 2:
City:
*
State:
*
--select a state--
WYOMING
WISCONSIN
WEST VIRGINIA
WASHINGTON
VIRGINIA
VERMONT
UTAH
TEXAS
TENNESSEE
SOUTH DAKOTA
SOUTH CAROLINA
RHODE ISLAND
PENNSYLVANIA
OREGON
OKLAHOMA
OHIO
NORTH DAKOTA
NORTH CAROLINA
NEW YORK
NEW MEXICO
NEW JERSEY
NEW HAMPSHIRE
NEVADA
NEBRASKA
MONTANA
MISSOURI
MISSISSIPPI
MINNESOTA
MICHIGAN
MASSACHUSETTS
MARYLAND
MAINE
LOUISIANA
KENTUCKY
KANSAS
IOWA
INDIANA
ILLINOIS
IDAHO
HAWAII
GEORGIA
FLORIDA
DELAWARE
CONNECTICUT
COLORADO
CALIFORNIA
ARKANSAS
ARIZONA
ALASKA
ALABAMA
Zip:
*
Country:
United States of America
Primary Phone:
*
Alternate Phone:
E-mail Address:
*
Other
Insurance
*
Excluding yourself, how many guests will you bring?
*
0
1
2
3
4
Additional Information
How did you hear about this seminar?
*
Please Select
Baptist East/Milestone Wellness Center
Baptist East newsletter (About You)
Baptist East newsletter (Bugle)
Baptist East newsletter (Healthy You)
Baptist East newsletter (InSights)
Baptist East newsletter (WellMail)
Baptist East newsletter (Wellness55)
Brochure/Flyer
Friend/Family
From a Baptist East employee
I am a Baptist East employee
Newspaper
On-hold message
Other
Primary Care Physician
Physician
Radio (station unknown)
Radio - WAMZ-FM
Radio - WHAS-FM
Radio - WRKA-FM
Radio - WVEZ-FM
TV
Web site
Please tell how you heard of this seminar:
Please Select
Abraham, Ann.
Ahmed, Nuzhat.
Bermudez, Jairo.
Blevins, Thomas.
Bui, David.
Butler, David.
Castro, Marcp.
Coats, Dr.
Dasso, Nanci.
Dayal, Vivek.
Friedman, Alice. D
Fung, Frederick.
Gerdelman, Brenna.
Guerrero, Laura. J
Gupta, Ajay.
Hall, Robert.
Hart, Steven.
Hathcock, Ann.
Ho, Kevin.
Hood, Jerry.
Howell, Shelly.
James, Jeffrey.
Jere, Sajata.
John, Paul.
Kadhim, Thikra. J.
Lambeth, James Eric.
Lewis, William.
Mahale, Radha.
Mandalapu, Bhuvana.
Marcus, Howard.
McDonough, Joan.
Miller, Hillary.
MITCHELL, CHARLES.
Mohandas, Arjun.
Nara, R.
Neavel, Celia.
Nemawaker, Anjala.
Paul, Love. D
PCP-Peck, Jason.
Poonawala, Robina.
Poreddy, Vijay.
Prakash, Rajeev.
Ravakhah, Keyuan.
Reddy, Dr.
Rogers, William.
Ruiz, Marilyn.
Schuller, Mike.
Shaw, Stephanie.
Shung, Sheila.
Sierk, Phyllis.
Stockel, Mark.
Sullivan, Daniel.
Toupin, Leo.
Webster, David.
Whited, Everest. A
Other
Please Select
Akin, Mark.
Alamia, Rodolfo.
Baldacchino, Thomas.
Blevins, Thomas.
Bozard, Dr. .
Brown, Thomas .
Byrne, Dorothy.
Casaubon, Luis .
Casaubon, Luis.
Cetin, Derrick.
Chalkias, Fontini.
Chauhan, Manish.
Collins, Melanie.
Emerson, Peter .
Espinosa , Valerie .
Ezekoye, Olufunke. E
Friedman, Alice.
Hansard, Lisa.
Hawthorne, Andy.
James, Jeffery .
Jhangiri, Sarnza.
KKKt, Cihek.
Lieberman, Thomas.
Long, Chad.
Malinoswki, Dorata.
Mandalapu, Prasad.
Mejia, Jose.
Miller, Hillary.
Nara, R.
Nemawarker, Anjali .
Neyman, Sherry.
Paul, Love. D
Peveto, Patrick.
Poreddy, Vijayrama.
Porter, Barbara .
Posner, Dr.
Punjabi, Narenda.
REF-Wellington, Brandy.
Shaw, Stephanie.
Toupin, Leo.
Vani , V.
Wallia, Arvinder.
Webster, Dave.
Wellmon, Brandy.
Other
