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In-Person Seminar Registration
Please complete the form to register for an upcoming Weight Loss Surgery in-person seminar. The seminar will be held in the Hannibal Regional Conference Center which is located inside the Hannibal Regional Medical Group main entrance.
First Name
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Last Name
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Date of Birth:
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Phone Number
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Email Address
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Mailing Address:
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City:
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State:
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AL
AK
AZ
AR
AS
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
TT
UT
VT
VA
VI
WA
WV
WI
WY
Zip Code:
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I am interested in learning more about:
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Medical options for weight loss.
Surgical options for weight loss.
Undecided.
You are registering for an in-person seminar. Please complete our
New Patient Health History form
. Upon completion, this will be securely transmitted to our office. Alternatively, a paper copy of the form is available - contact our office prior to your seminar date to have this emailed, mailed, or ready for pick-up. Having the New Patient Health History completed prior to your seminar date will allow you to schedule an initial appointment at the conclusion of the seminar.
If you would like to expedite the intake process, please return to the
Bariatric Surgery page
and click the
"View Seminar Online"
button to view our online seminar and complete your New Patient Health History form. When we receive the information in our office, a member of our team will reach out to you right away to schedule your initial evaluation.
Thank you for choosing Hannibal Regional Weight Management Solutions!
Select the date you plan to attend
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Thursday, November 21, 2024 @ 2:00 p.m.
Thursday, December 19, 2024 @ 2:00 p.m.
Thursday, January 16, 2025 @ 2:00 p.m.
Thursday, February 20, 2025 @ 2:00 p.m.
Thursday, March 20, 2025 @ 2:00 p.m.
Thursday, April 17, 2025 @ 2:00 p.m.
Thursday, May 15, 2025 @ 2:00 p.m.
Thursday, June 19, 2025 @ 2:00 p.m.
Thursday, July 17, 2025 @ 2:00 p.m.
Thursday, August 21, 2025 @ 2:00 p.m.
Thursday, September 18, 2025 @ 2:00 p.m.
Thursday, October 16, 2025 @ 2:00 p.m.
Thursday, November 20, 2025 @ 2:00 p.m.
Thursday, December 18, 2025 @ 2:00 p.m.
How did you hear about our program?
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Billboard
Facebook
Internet Search
Magazine
Healthcare Provider
Word of Mouth
Television Commercial
Radio
Other
Name of Healthcare Provider:
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Which radio station?
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Please explain:
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