Attestation for Online Seminar

It is extremely important that you know exactly what you are getting into. The seminar is your first exposure to our program and our unique philosophy in managing weight loss long term. We have very clear beliefs and want to help you evolve into a new life. With that in mind, we have developed our online seminar as a way to help those who cannot travel to Summerville for an evening seminar to still have exposure and benefit from the education we teach during that lecture. I have tried to make it as entertaining and informative as possible but I still recognize that you are watching a computer screen and dealing with the distractions of everyday life. Please watch the seminar in a quiet room free of distractions and if need be, take the time to watch it again.

After all, if you eventually get the opportunity to have surgery, your life and very survival are dependent upon your understanding and ability to follow the instructions within the program. If you have any questions after viewing this seminar, please call the office at: (843) 875-8994.

Upon full completion of this form we will contact you to schedule your first appointment with Dr. Neil McDevitt or Dr. Michael Michel. If you have not heard from the office within 3 business days, please call (843) 875-8994 or email to confirm that we have received your information.

All fields with an asterisk (*) are required.

Thank You

The form was submitted successfully.

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

Save and Resume Later

Save and get link

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

Apply Discount

You saved

with code

Submit Form

Submitting

Validating

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Please check the field:

Fields

I have watched the online Coastal Carolina Bariatric Center Information Seminar in its entirety and have had the opportunity to discuss my questions and concerns with the doctors and staff of Coastal Carolina Bariatric Center.*

I have watched the online Coastal Carolina Bariatric Center Information Seminar in its entirety and have had the opportunity to discuss my questions and concerns with the doctors and staff of Coastal Carolina Bariatric Center.

Name*

First Name*

Last Name*

Date of Viewing Seminar*

https://www.formstack.com/forms/images/2/calendar.png

Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year

2022 2023

For each question, please check all that apply

Name the types of surgery performed at CCBC:*

Lap-Band Roux en Y Gastric Bypass Sleeve Gastrectomy Duodenal Switch or Biliopancreatic Diversion

BMI stands for Body Mass Index. Which BMIs are considered obese?*

25 30 35 40

Who is eligible for Bariatric Surgery?*

BMI 34, otherwise healthy BMI 35 with diabetes BMI 40 BMI 29

Who is not eligible for Bariatric Surgery?*

Tobacco user Active substance abuse Female who wants to become pregnant within 18 months after Gastric Bypass Someone medically unable to survive surgery

Which are complications of the Lap-Band?*

Slippage Leakage of the band or mechanical failure Infection Worsening Vision

Which are complications of the Sleeve Gastrectomy?*

Worsening Reflux Hot Flashes Infection Leakage of the Staple Line

Which are complications of the Roux en Y Gastric Bypass?*

Sinus Infections Leakage of the Staple Line Twisting of the Intestines Bleeding

Which supplements do Roux en Y Gastric Bypass patients have to take every day for the rest of their lives?*

B12 Calcium Multivitamin Iron

What are possible side effects of the Roux en Y Gastric Bypass?*

Dumping Syndrome Hair Loss Depression Nausea

Contact information

The hard part is over. The rest of the questions should be really easy to answer. Please complete the following demographic information so that we can contact you to schedule your first appointment.

Name*

First Name*

Last Name*

Age*

Email*

Phone*

Address

Address Line 1

Address Line 2

City

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State

ZIP Code

How did you hear about our online seminar?

Upon submission of this form we will contact you to schedule your first appointment with Dr. Neil McDevitt or Dr. Michael Michel. If you have not heard from the office within 3 business days, please call (843) 875-8994 or email CCBSInfo@hcahealthcare.com

Previous← Next→

Enter your save and resume password

Cancel

Confirm