Weight Loss Surgery Support Group
Beginning January 2025
Mental Health Clinicans
Dr. Monica Alharazim, Sarita Boyette, LPC, & Dr. Umieca N. Hankton
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
Which state are you located?
Did you have the sleeve, gastric bypass, or duodenum? When did you have surgery? If you have not had surgery yet, please type N/A.
I’m interested in joining the following support group:
Please Select
Pre-bariatric surgery Support Group
Relapse Support Group
Weight Loss Support Group
Please share any questions you have below. We look forward to sharing support group details with you.
Signature: By signing this form, I am giving permission to use the telephone number and email listed to contact me for information about the selected support group.
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