Lap Band Patient Forms and Registration

Patient registration forms

We offer two ways of completing your registration forms in preparation for your appointment.

You can enter your form on our online service. Have your insurance card available and enter that information online so that we can help to begin verifying your benefits.

You can download our forms and print them out to fax them or mail them to us. You will need to have Adobe Acrobat reader to open the files.

Online registration	Download and Print Forms

For those preparing for surgery we have our consent forms available here.

First / Last Name*

Phone Number*

Email Address*

Height*

Weight*

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Maxcine has lost 89 pounds in a little over a year, and is still going strong! She used to take 15 medication pills per day, and is off of all of them. Way to go Maxcine!
We call Jeff "Mr Lap Band Oklahoma!" Jeff lost 130 pounds in the first year after Lap Band surgery. Here he is showing off with the belt he used to wear!
Kelli was just 19 years old when she had her Lap Band and lost over 170 pounds in the first year after surgery.
Amy has lost 78 pounds since surgery and has more energy and feels better than she did before!