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Gender Male Female Other Prefer not to disclose
Height (Ft)
Height (In)
Weight (lbs)
Procedure Interests Adjustable Gastric Band Duodenal Switch Gastric Balloon Gastric Bypass Revisional Surgery Sleeve Gastrectomy Unsure/I Want to Discuss With a Doctor
Initial Patient Insurance 1199 AETNA BCBS CIGNA CT CARE EMBLEM EMPIRE GEHA GHI HCP HIP MAGNACARE MEDICAID MEDICARE NYSHIP OXFORD SELF PAY SURGERY PLUS UHC UMR
How did you hear about us? Internet Billboard TV Radio Facebook Doctor Referral Friend Referral Insurance Company referral Bariatric Surgery Source Other
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