Patient Medical History Form

Patient Information Form
Patient Name*

First NameLast Name
Name you prefer to be called:*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Patient Birth Date*

MonthDayYear
Patient Age*
Patient Height*
Patient Sex*
Patient E-Mail*
Primary Care Physician*
Occupation*
List any medications (prescribed/over the counter)*
Who can we thank for referring you to our office?*
Example: Friend/Family first & last name or Google
Are you currently on our schedule? If not, please call 803-329-8446 to pick your appointment time.*
Financial Policy:

Thank you for choosing Complete Medical Weight Loss Clinic. We are honored to service you during your weight loss journey. Please be advised that payment for your visit is due in full at the time services are rendered. For your convenience, we accept Visa, Mastercard, Amercian Express & cash and personal checks. A $10 fee will be charged for all returned checks. No refunds are given at any time. We do not submit claims to insurance companies. If you would like to do so on your own, we will be happy to provide you with an itemized receipt. We are unable to accept returns on any medicine after it has been dispended to you, due to medicine dispencing regulations. I have read and understand the above statements and have agreed to these statements.
Patient Signature*

Clear

Patient Information Form