Remote Monitoring Trial Application

Remote Monitoring Trial

Completely confidential with no obligation!
Client Agreement
RPM Applicant
Comment
📢🎈 Thank you for diving into our bariatric research trial! 🌟 Here are some cool perks:

📈 Keep tabs on your health stats.
🎓 Learn from top-notch experts.
🚀 Be at the forefront of innovative research.
🎁 Earn Monthly prizes and be featured in our monthly newsletter
🔒 Rest assured, your information is completely private with us.

Ready to get started? Complete the form below! 👇
Please verify that you are human*
Client Status

I have already had bariatric surgeryI plan to have bariatric surgery
What type of bariatric surgery did you have?
When did you have bariatric surgery?

MonthDayYear
Date
Where did you have bariatric surgery?
Hospital/Clinic - Location (USA, Canada, Mexico) etc.
How was your surgery funded?
Surgery Comments
Provide any additional comments on your surgery here
Do you need a wearable device, or plan to use your own. i.e. Apple watch, fitbit etc.

I already have a wearable deviceI need a wearable device shipped
Type of Wearable?
If you plan to use your own wearable
Name

First NameLast Name
Patient Gender
Patient Birth Date

MonthDayYear
Age
Nationality
Height
Current Weight
Planned Weight
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number for call or Text SMS

Area CodePhone Number
E-Mail
Additional comments or questions
Signature

Clear
Thank You for Completing!

PLEASE SUBMIT BELOW WHEN COMPLETE.
We will review your information and get back with next steps. In the interim please let us know if you have any questions.
More More Information please visit www.gorgeousgetaways.com
Should be Empty:

Remote Monitoring Trial

Thank You for Completing!