Bariatric Treatment Centers - BTC Ad Response Form

If you just saw an ad for Bariatric Treatment Centers, we'd like to hear from you - and send you a free information kit! Simply fill out the form below and your free kit should arrive within 7-10 days.

name

address

city

state

zip

daytime phone

e-mail

height weight date of birth

health insurance company

How did you learn about Bariatric Treatment Centers?
(please check any of the following that are appropriate)

TV ad

This Web site

Magazine ad, please fill in: 800-363-4303 ext.

Newspaper ad, please fill in: 800-363-4303 ext.

Radio ad

Brochure

Mailer

AOL

Friend

Bariatric Treatment Centers patient

Your doctor

www.obesityhelp.com

Other (please specify)

comments

Please contact me to schedule a consultation with a BTC specialist.

Please send me more information about BTC's weight loss program.

Please contact me to answer my questions.