Fayetteville: 877.445.6460 / Fort Smith: 479.434.6222

Patient Information Form

Thank you for your interest in the Roller Weight Loss Online Seminar.

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We look forward to meeting you!


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Thank you for providing this information. Once we receive this form, along with step two of the registration process of submitting your registration fee, our office will give you a call to schedule your first appointment. Congratulations on taking the next step to a new you!