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<blockquote><p style=”text-align: center;”>

Weight Loss Surgery Seminar (in person) Registration

System Requirements:

Your computer must have access to Youtube and be capable of playing Youtube videos.

Important:

After the video, you must successfully complete a 12 question quiz to ensure that you understand the material presented in the seminar. YOU WILL NEED TO PRINT YOUR TEST RESULTS INCLUDING YOUR CONFIRMATION NUMBER, OR YOU MAY SIMPLY WRITE DOWN THE CONFIRMATION NUMBER.

First Name
Last Name
Phone
Email Address*
Retype Email Address*
Birth Month and Day /











</p>
<p style=”text-align: center;”>or register below to attend a seminar in person.</p>
<a name=”live”></a>

<form action=”https://www.pikevillehospital.org/blog_weight_loss_process.php” method=”post” name=”myForm”>
<div align=”center”><span class=”wltext” style=”font-weight: bold;”>Register for a FREE Weight Loss Surgery Seminar</span></div>
<p class=”wltext” style=”text-align: center;”>Please complete the following form to register for an upcoming informational seminar. Seminars are held on the third Tuesday of the month at 6pm in Dining Room 2 on the 11th Floor of the May Tower. If you would prefer to register via phone, please call our office at 606-218-2205</p>

<div align=”center”>

All fields are required
<table>
<tbody>
<tr>
<td class=”wltext” colspan=”2″ valign=”top” width=”450″>Name <input name=”name” size=”20″ type=”text” /></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Email</td>
<td class=”wltext” valign=”top” width=”300″><input name=”email” size=”20″ type=”text” /></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Confirm Email</td>
<td class=”wltext” valign=”top” width=”300″><input name=”email2″ size=”20″ type=”text” /></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Address</td>
<td class=”wltext” valign=”top” width=”300″><input name=”address” size=”20″ type=”text” /></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>City</td>
<td class=”wltext” valign=”top” width=”300″><input name=”city” size=”15″ type=”text” /></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>State</td>
<td class=”wltext” valign=”top” width=”300″><select name=”state”>
<option selected=”selected” value=”KY”>Kentucky</option>
<option value=”AL”>Alabama</option>
<option value=”AK”>Alaska</option>
<option value=”AZ”>Arizona</option>
<option value=”AR”>Arkansas</option>
<option value=”CA”>California</option>
<option value=”CO”>Colorado</option>
<option value=”CT”>Connecticut</option>
<option value=”DE”>Delaware</option>
<option value=”DC”>District Of Columbia</option>
<option value=”FL”>Florida</option>
<option value=”GA”>Georgia</option>
<option value=”HI”>Hawaii</option>
<option value=”ID”>Idaho</option>
<option value=”IL”>Illinois</option>
<option value=”IN”>Indiana</option>
<option value=”IA”>Iowa</option>
<option value=”KS”>Kansas</option>
<option value=”LA”>Louisiana</option>
<option value=”ME”>Maine</option>
<option value=”MD”>Maryland</option>
<option value=”MA”>Massachusetts</option>
<option value=”MI”>Michigan</option>
<option value=”MN”>Minnesota</option>
<option value=”MS”>Mississippi</option>
<option value=”MO”>Missouri</option>
<option value=”MT”>Montana</option>
<option value=”NE”>Nebraska</option>
<option value=”NV”>Nevada</option>
<option value=”NH”>New Hampshire</option>
<option value=”NJ”>New Jersey</option>
<option value=”NM”>New Mexico</option>
<option value=”NY”>New York</option>
<option value=”NC”>North Carolina</option>
<option value=”ND”>North Dakota</option>
<option value=”OH”>Ohio</option>
<option value=”OK”>Oklahoma</option>
<option value=”OR”>Oregon</option>
<option value=”PA”>Pennsylvania</option>
<option value=”RI”>Rhode Island</option>
<option value=”SC”>South Carolina</option>
<option value=”SD”>South Dakota</option>
<option value=”TN”>Tennessee</option>
<option value=”TX”>Texas</option>
<option value=”UT”>Utah</option>
<option value=”VT”>Vermont</option>
<option value=”VA”>Virginia</option>
<option value=”WA”>Washington</option>
<option value=”WV”>West Virginia</option>
<option value=”WI”>Wisconsin</option>
<option value=”WY”>Wyoming</option>
</select></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Zip Code</td>
<td class=”wltext” valign=”top”><input name=”zip” size=”10″ type=”text” /></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Phone</td>
<td class=”wltext” valign=”top”><input name=”phone” size=”10″ type=”text” /></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Contact Preference</td>
<td class=”wltext” valign=”top”><select name=”communication”>
<option value=”phone”>Phone</option>
<option value=”email”>Email</option>
</select></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Date Attending
(See calendar below)</td>
<td class=”wltext” valign=”top”><input name=”date” size=”25″ type=”text” /></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Where did you hear about us?</td>
<td class=”wltext” valign=”top”><select name=”marketing”>
<option value=”Not specified”>Please Choose One</option>
<option value=”Google”>Google</option>
<option value=”OtherInternet-non-Google”>Other Internet Search</option>
<option value=”Newspaper”>Newspaper</option>
<option value=”Friend/Relative”>Friend/Relative</option>
<option value=”Television”>Television</option>
<option value=”Billboard”>Billboard</option>
</select></td>
</tr>
<tr>
<td class=”wltext” align=”right” valign=”top” width=”150″>Help us reduce SPAM by answering the following question. How much is 3 plus 2?</td>
<td class=”wltext” valign=”top”><input name=”chknum” size=”2″ type=”text” /></td>
</tr>
<tr>
<td colspan=”2″ align=”center” valign=”top”><input name=”submit” type=”submit” value=”Submit” /></td>
</tr>
</tbody>
</table>
</div>
</form><span style=”color: #ffffff;”>..</span>

[ai1ec view=”monthly” cat_name=”Bariatrics”]