To Be Completed to be Considered for Participation in MGB Writers Group

Please List your full details:  Hospital and Practice contact Information for listing as author or participant in subsequent studies/papers/publications.

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* 1. Physician ID

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* 2. Willing to Comple and Email to Dr Rutledge the necessary
Conflict of Interest Form Emailed to DrR@clos.net

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* 3. Do You Offer the Mini-Gastric Bypass / One Anastomosis Gastric Bypass?

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* 4. What is the *Estimated TOTAL* number of MGBs you have performed ?

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* 5. Estimated Number (#) of MGB Operations in your Practice last 12 months

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* 6. Keep my information confidential Y/N

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* 7. Estimated Number (#) of years performing MGB:

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* 8. Other Comments, Questions or Suggestions

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* 9. What Name Do You Suggest/Prefer for the Group?

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