Name Interest Gastric Bypass Lap Band® Sleeve Gastrectomy Revisional Weight Loss Surgery Undecided Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Home PhoneWork PhoneHeight Weight Insurance Information Seminar Date RequestedSeminar Date RequestedJanuary 16th, St. Vincent's East, Dr. Jay C. LongFebruary 6th, St. Vincent's East, Dr. Jay C. LongMarch 6th, St. Vincent's East, Dr. Jay C. LongApril 3rd, St. Vincent's East, Dr. Jay C. LongMay 1st, St. Vincent's East, Dr. Jay C. LongJune 19th, St. Vincent's East, Dr. Jay C. LongJuly 10th, St. Vincent's East, Dr. Jay C. LongAugust 14th, St. Vincent's East, Dr. Jay C. LongSeptember 11th, St. Vincent's East, Dr. Jay C. LongOctober 2nd, St. Vincent's East, Dr. Jay C. LongNovember 6th, St. Vincent's East, Dr. Jay C. LongDecember 11th, St. Vincent's East, Dr. Jay C. LongComments*Preferred Contact MethodPreferred Contact MethodEmailPhoneCAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
