Your Full Name (required)

Your Email Address (required)

Date of Birth (required)

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Please select which type of consultation you would like to arrange:

—Please choose an option—30 min 'new' gastric band adjustment consultation £16015 min 'follow-up' gastric band adjustment consultation £100

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Date of Operation (required)

Name of Surgeon (required)

Make of Gastric Band

Maximum fill volume of gastric band

Please enter the four characters above in the field below

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