HOLIDAY PARTY RSVP

Please Enter Your Information

*Required fields.

First Name *

Last Name *

Email *

Phone *

Your Surgeon *

Dr. Bilof Dr. Yurcisin

Your Street Address *

City *

State *

Zip Code *

Your Procedure *

Sleeve Bypass DS Band Other

Date of Procedure

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Friends and Family Guest List

Please enter the amount of guests that will be attending with you.

Total Guests

Add Comments

Please enter the verification information below

Verification #: 68273

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