Ambassador Application

Thank you for you interest in the NewHope Bariatrics Ambassador program. Due to the overwhelming response to the program, space for Ambassadors is limited. If you are chosen for the program, you will be contacted directly. Please continue to monitor this page for updates about the program and feel free to re-apply as often as you like. Thank you again for your interest and support. We wish you continued success with your band.

If you would like to submit your information via fax, please download this file, print and send completed application to:

704-973-9887

First Name

Last Name

Telephone

Address

City

State

Zip

Occupation

Surgeon

Date of Birth

Date of Surgery

Weight Lost to Date

Current BMI

Pre-Op Comorbidities

Current Comorbidities

Before Photo Upload

After Photo Upload

Questions

What was your motivation to pursue weight-loss surgery?

Why did you choose the LAP-BAND system?

How has the LAP-BAND changed your life since surgery?

What is your greatest weight-loss success?

What is your greatest weight-loss challenge?

Describe yourself in five words.

Why do you want to encourage others to explore gastric banding surgery?

Why do you think you’d be the right person to educate others about gastric banding and encourage them to explore surgery for themselves?

What would you hope to accomplish as a newhope ambassador?

By checking this box, I agree that I am voluntarily providing personal health information. It can be shared with other third-parties for the consideration of promotional and educational opportunities.

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