Weight Management

*This is for weight management only and our office will not be responsible for your chronic medications and testing. Please contact your family doctor if you need medications other than what we will be prescribing.

The first visit is $125 and each visit after is $75. This is due at the time of service. This fee does not include the medication. If we participate with your PPO insurance, we will submit the office visit to your insurance. Please bring your Driver's License and insurance card to the appointment. Please note, we do not accept any form of medical assistance.

We will ask about insurance information when we call you to schedule.

Thank you.

In your lifetime, what has been your highest recorded weight ?*

Goal Weight?*

Please explain what diets and/or weight loss tools you have used in the past. Please indicate the most successful with an (*) : *

Are you diabetic?*

YesNo

Any personal thyroid disorders?*

YesNo

Any personal history of pancreatitis?*

YesNo

Any personal history of gallbladder issues?*

YesNo

If Yes, what gallbladder issues?

Any personal history of GERD or other gastrointestinal diagnosis?*

YesNo

If Yes, what type of GI issues?

Family history of medullary thyroid carcinoma?*

YesNo

Family history of multiple endocrine neoplasia syndrome type 2?*

YesNo

Signature of patient*

How did you hear about this program?*

Please verify that you are human*