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1. Name:

2. City and state: Fort. Hood, Texas

3. Are you a Southern California resident? No

4. Would you like to be added to our in person luncheon guest list?

Yes

3. Email address:

4. Obesity Help Profile name and/or OH URL: None at this time

5. Are you: Considering Surgery, Pre Op or Post Op: Pre-Op

6. Date of WLS: to be determined

7. Surgeon's Name: To be determined

8. Type of Surgery: RNY

9. Highest Pre Surgery Weight: 286

10. Insurance or self pay: Insurance

11. What is the name of your insurance company that covered your WLS:

Tri-care Prime

12.Birthdate: 12/10/1985

13.Occupation: none at this point

14.Hobbies: Tennis, scrapbooking, reading, writing, making clothes

15.Anything you would like the other members to know about you?

Please feel free to omit any information you don't wish to share.

Your privacy is respected!

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