Registration Form for Free Weight Loss Surgery Information Session - Gastric Bypass and LapBand

* Please note that our program does not currently accept Medicaid/Medicare patients or individuals more than 59 years old due to medical requirements/restrictions.

We look forward to seeing you at one of our free information sessions. To register online, please fill out the form below. Dates of sessions are listed below this form for your convenience.

Click here to download an application to our program
(Applicants are required to attend an information session, but you may bring a completed application with you to the session)

* Required Fields

First Name
* Last Name *

Address
*

City
* State *
Zip Code
*

Email Address

Phone Number

Session Date You'll Be Attending

How Many People Will Be Attending?
*

How Did You Hear About the Session?

If you selected other, please indicate how you heard about the session.

If a physician referred you, what is the physician's name?

Who is your insurance carrier?

Who is your employer?

Which Surgery Are You Considering?

If you do not want to receive additional online communication from Portsmouth Regional Hospital or Parkland Medical Center, please click the box above.

General Internet communication is inherently not secure. For this reason, we highly recommend that data considered confidential or private in nature not be submitted on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.)

Due to federal government requirements/restrictions, the NH Medical and Surgical Weight Loss Center cannot accept patients over the age of 59 or with Medicaid at this time.

Click here to download an application to our program
(Applicants are required to attend an information session, but you may bring a completed application with you to the session)