First Name *

Weight Loss Visit Intake Form

Last Name *

Street Address *

Address Line 2

City *

State *

Patient Date of Birth: * +

I agree to receive texts from the prescriber and the pharmacy. *

I agree

Zip Code *

MOBILE Phone Number *

Email Address *

Do you have any food or drug allergies? *

Yes

No

Please describe any food or drug allergies below: *

Please check any of the following you have ever had: *

Please describe the issue(s) checked above: *

Do you have any other past or present medical conditions not listed above (NOT including routine surgeries)? *

Yes

No

Please list any other past or present medical conditions not listed above: *

Have you ever had any surgeries that were NOT weight loss surgeries? *

Yes

No

Please list previous NON weight loss surgeries:
(type none if you have not had any surgeries) *

Have you ever had weight loss surgery? *

Yes

No

Approximate date of surgery: *

What type of surgery and what was your experience? *

Highest Pre-Surgery Weight: *

Lowest POST-Surgery Weight: *

Family medical conditions on your mom's side:
(type none if there are none or you don't know) *

Family medical conditions on your dad's side:
(type none if there are none or you don't know) *

Please list all current medications (or supplements), strength, frequency, and purpose:
(type none if you are not currently on any medications) *