Exit this survey Medical Weight Loss Online Seminar Acknowledgement NEW Question Title * 1. My first and last name is: Question Title * 2. My height is: Question Title * 3. My weight is: Question Title * 4. The name of my primary insurance company is: Question Title * 5. Please provide the following insurance information. Name of insured Street Address City, State and Zip Employer name for insured Date of Birth for Insured Policy/ID number Group number HMO or PPO Insurance company phone number Date of birth for patient Question Title * 6. My phone number is: Question Title * 7. My email address is: Question Title * 8. By selecting Yes, I authorize the Center for Weight Management, a service of Gwinnett Medical Center to verify my insurance benefits. Yes No Question Title * 9. By selecting Yes I acknowledge that I have viewed the online seminar. Yes No Question Title * 10. I heard about this program through: From the Heart Caring Chronicles Internet Friend/Family Physician Print Ad (newspaper/magazine) Billboard Radio If physician, please provide name: Done