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Information Request Form

If you're intersted in learning more about Bariatric Treatments Centers' surgical weight loss program, fill out the form below and we will send you a free information kit. It should arrive in 7-10 days.


Contact BTC
   


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address

 
   

city

 
   
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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
Friend
Bariatric Treatment Centers patient
Your doctor
AOL
Mailer
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 questions I have.

   

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