Medical Seminar Registration

Please complete the following registration form to sign up for a medical weight management seminar. After completion, you will receive a confirmation email notifying you that your registration has been accepted.

Patient Information

First Name:*
Last Name:*
Last 4 Digits of SSN:*

Home Phone:*
Work Phone:
Cell Phone:
Email Address:*
Gender:* Male Female
Date of Birth:* (MM/DD/YYYY)
Height: ft in
Weight: lbs
Insurance Provider Name:*
Please choose your preferred location?*
How did you learn about the medical Weight Management Center programs? *
Are you interested in attending an information session online or in-person? *

Quick Reference

Weight Management Center


Mon - Fri, 8:30 to 4:30
Find us at:
4614 Country Club Road Winston-Salem, NC 27104.

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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.