Finance Program Application

LAP-BAND® Finance Program Application Form

What is your name?
First :
Last :

What is your address?
Apt No :
City :
State :
Zip :

What is your email address?
Email :

What is your telephone number?
Telephone Number :

What is the name and location of your surgeon?
First Name :
Last Name :
City :
State :

Have you or your head of household declared bankruptcy in the past 3 years?
Yes
No

Have you or your head of household been employed with the same employer for more than 6 months? Remember that being self-employed is considered employment.
Yes
No

Do you or your head of household have collateral such as a home, vehicle or other asset?
Yes
No

Trace W. Curry, M.D.