One of our qualified counselors, will discuss your information
with the doctor and will get in touch with you as soon as possible.
 
Full Name:
 
Occupation:
 
Address:
 City  State  Zip
 
Home Phone:
 
Work Phone:
 
Cell Phone:
 
Fax:
 
E-mail:
 
BirthDate:
 How were you referred to us:
specify 
  What is your BMI?
 Your Age  Your Height  Your Weight
 
Goal Weight:
 Previous weight loss treatment (if yes-explain) Yes No  
   
specify
 Previous weight loss surgeries (if yes-explain) Yes No  
   
specify
 Do You have any medical problem (if yes-explain) Yes No  
   
specify
 Are you allergic to any medication (if yes-explain) Yes No  
   
specify
 Are you taking any medications (if yes-explain) Yes No  
   
specify
 Are you Interested in Financing ? Yes No  
 I am interested in information on... Lap Band Plastic Surgery Gastric Bypass
 Time frame for surgery ?
 Best time to call you ?
Will your surgery be covered by insurance? Yes No  

Solution 4 Obesity takes pride in our unblemished reputation and our many satisfied clients.
We invite you to check our feedback, speak with our past clients and ask others about us as individuals and as a business entity.
We strongly urge you to do your own investigation of any company you decide to trust.
 

This privacy statement discloses our information gathering and dissemination practices for www.solution4obesity.com
 
Due to the nature of Internet communications, no privacy statement –including this one-- can address all the factors on the visitor's system or the systems involved in connecting visitors to our site. We will do our best to uphold privacy on our end of the communications.

This website was created for Southern Professional Allinace, LLC DBA Solution 4 Obesity.  Your identity, contact and medical information will be treated absolute confidentially and will not be shared with any organizations or individuals outside Solution 4 Obesity and will be used for the sole purpose of determining your eligibility for the medical procedures you have expressed interest in.

  • Solution 4 Obesity will make the information provided on your e-letter and application available only to the medical and office staff of the doctors we represent.
  •  The email addresses of those who fill out an e-letter are stored in a database. This database will be used for client contact information for our doctors and staff.  
  • Solution 4 Obesity will not sell any personal or medical information you provide (such as your name or contact information), nor will it make available your information to any organization or individual without your express consent.

Outside Links
This site contains links to other sites. www.solution4obesity.com is not responsible for the privacy practices or the content of such Web sites.

Web Site Statistics
Statistics kept on this site aggregate usage information for campaign evaluation purposes. These statistics do not reveal personal information.

If you have any questions about this privacy statement, the practices of this site, or your dealings with this Web site, you can contact: info@SouthernProfessionalAlliances.com

 

  


Southern Professional Alliance, LLC (dba Solution 4 Obesity) is a scheduling facilitator; we are not a healthcare provider. Solution 4 Obesity shall not be liable to you or anyone else for any decisions made or action taken in reliance on this information. This information does not constitute medical advice and does not create any physician-patient relationship.

Copyright 2007 Southern Professional Alliance, LLC