TQ-Remote Monitoring Trial Applications

Remote Monitoring Trial

Completely confidential with no obligation!
Client Agreement
RPM Applicant
Client Status

I have already had bariatric surgery in the past 6 monthsI plan to have bariatric surgery in the next 3 to 6 months
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
Name

First NameLast Name
Patient Gender
Patient Birth Date

MonthDayYear
Age
Nationality
Height
Current Weight
Planned Weight
Address (where device is to be shipped)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone/Mobile Number

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