Center for Bariatric Nutrition
Contact Form and Beta Tester Application

Thank you for visiting the Center for Bariatric Nutrition. At present we are accepting applications to participate in our Beta-test program. If you would like to participate or are seeking additional information please complete the information below. One of our staff members will contact you within 48 hours to discuss your application.

Learn more about the Beta Tester
program and role <click here>.

We are taking applications for ONLY 7 more beta testers for our new online nutritional guidance program specifically designed for Bariatric patients. In total there will be 100 beta testers from all around the world!

Please take a moment now and complete this form to be a beta tester for The Center for Bariatric Nutrition. Do not delay as this message is being sent to nearly 300 people who showed interest and we only have space for 7 more people.

 

Thank you for your interest in the beta program. All individuals accepted into the beta program will receive one year of our silver package services at NO COST. If you are chosen to remain a beta tester past July 2008 you may be entitled to a life of free Center for Bariatric silver services.
 

Please provide the following contact information in as much detail as possible:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone
E-mail
URL

Tell us a little more about yourself:

Surgery Type
Date of Birth
Sex Male Female
Height (example: 5'7")
Current Weight (example: 200)
Start Weight (example: 327)
Current BMI (example: 21)
Start BMI (example: 47)

Choose one of the following options:

More Information (Add comments below)
I'd like to be a beta tester (tell us why in the comments field)
 Suggestion
Complaint

How did you hear about us?

Name of person, website or search engine:

Additional Comments & Why you would like to be a beta-tester:


              

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