Request Referral Pads For Your Surgical Practice

We’ve recently learned that several surgical practices are recommending our blogs as a support resource for their lap band patients.  We are thrilled to be able to pay it forward to the banded living community.

In order to make it easier for you to refer patients, we can send you referral pads (see sample on right).   Referral pads are already in use in several practices across the US.  If you would like receive some, please complete the form below:

Name
Email
Phone
Secondary Phone
Address1
Address2
City
State
Zip
Country
Fax
Name of Surgical Practice
Surgical Practice Website URL
No. of Referral Pads Requested

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