Weight Loss Consultation Intake Form

Weight Loss Consultation Intake Form
Full Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is motivating you to begin your weight loss journey?
Have you previously attempted to lose weight using any of the methods listed below?

Other
Please check any medical conditions you currently have or have had in the past:

Other
Please list any medications or supplements you are currently taking (include dosage):
Do you currently exercise?
Do you Smoke?

Other
Do you consume alcohol?

Other
If Yes to Exercise--- describe type and Frequency
If Yes to Alcohol, How much, how often
Current Height and Weight
What was your lowest weight?
What is your Goal weight?
What has been your biggest challenge in losing weight?
Do you experience any of the following?
Additional notes:
Signature
Date

MonthDayYear
Date
My Products
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Consultation
Please Note: A $75 consultation fee (standard copay for your initial visit) is required to schedule your first appointment. Routine follow-up visits are recommended every 3 months to monitor progress and adjust treatment as needed. Each routine 3-month follow-up visit carries a $75 fee. If a visit is scheduled for an issue unrelated to weight management, a separate visit fee will apply.(You will be redirected to PayPal to complete your payment.)

$75.00 Quantity

Total

$0.00
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Contact Info

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Weight Loss Consultation Intake Form

My Products

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