Share your success story

If you are a patient of Dr. Kuri's and would like to share your own success story to inspire other bandsters on their journey, please submit your testimonial by completing the form below.

Please include a before and after picture using the uploading
feature below. If you require assistance, please email us at testimonials@lapbandsurgery.com.

Name:
E-mail Address:	Phone Number:
Address:

City:

State:

Zip:

Starting Weight:	Current Weight:
Goal Weight:	Date of Surgery:

Before Picture Upload ( please upload a JPG no larger the 1M ):
After Picture Upload ( please upload a JPG no larger the 1M ):
Success Story:
I (hereinafter, "Patient"), hereby give permission to Dr. Pedro Kuri (hereinafter, "Doctor") to photograph the Patient and use such photographs, or those submitted by the Patient, and testimonials written by the Patient in all forms of media, for any and all promotional purposes including, but not limited to, advertising, publicity, display, audiovisual, exhibition, commercial or editorial use. The Patient hereby further consents to the reproduction and/or authorization by the Doctor to reproduce and use such photographs and testimonials for use in all domestic and foreign markets. The Patient hereby forever releases the Doctor and any of the Doctor's associates, affiliates, appointed advertising agencies and designated directors, officers, agents, employees and patients from any and all claims that arise or could arise from the use of the patients photograph and testimonial as stated herein above. I Accept These Terms

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