Weight Loss Intake Form

How much weight would you like to lose?
Current Weight
Height
In what time frame would you like to reach your goal?
What is the main reason for your decision to lose weight?
When and what are the reasons for your weight gain?
What would you say is the biggest obstacle(s) to your weight loss?
Previous diets tried and results for each:
Medical History
Primary physician and physician phone number:
Current Medications: (Please list all prescriptions. over the counter medications, vitamins, herbs, and/or dietary supplements):

Decatur Internal Medicine Center Weight Loss Clinic

Insurance Information
What type of insurance do you have?*
Employer
Name of Policyholder
Name of Primary Insurance
Insurance Policy Member Number or Contract Number
Group number
Effective Date
Medical insurance policies do not typically cover weight management care and related expenses, including labratory testing, electrocardiograms, prescription medication and related supplements. If your primary diagnosis is obesity, you may NOT bill your insurance company for a co-morbid condition. Doing so may result in a charge of fraud.

An appropriate receipt of payment will be provided to you.
Patient Signature

Clear
Please call our office before visiting 256-350-6363. PLEASE WAIT 24 HOURS AFTER FILLING OUT THIS FORM AND TALKING TO A STAFF MEMBER TO COME IN. Walk in hours for New Patients are Monday-Thursday 1-3pm.

Patients must have commercial insurance for certain medications. Please call your insurance to check on medication coverage.
Should be Empty:

Medical History