Program Registration

Name*
First Last
Email*
Enter Email Confirm Email
Cell Phone*
Appointment reminder preference*

Address*
Street Address City State ZIP Code
Birth Date*
MM slash DD slash YYYY
Your gender?*
Driver license number*
Required for prescribing medication
License State*
State
Which of our locations would you prefer?*

How did you hear about us?*
Please tell us the name of the physician or medical provider who referred you.*
Please tell us the name of your friend or family member who referred you.*
We have a program in place to reward patients who refer others to us. Please let us know the name of one person who referred you.
Which search engine did you use to find us?*
How did you learn of our services?*
How tall are you in inches (NOT FEET) (please see example below)*
60 inches = 5 feet | 64 inches = 5 feet 4 inches | 69 inches = 5 feet 9 inches
Please enter a number from 48 to 78.
How much do you currently weigh? (best estimate)*
BMI - Current estimate
What is your highest weight ever? (non-pregnant)*
BMI - Highest
What is your ULTIMATE weight goal?*
My weight gain has been:*
- sudden
- gradual
My struggle with weight started:*
- during childhood
- in my teens
- in my 20's
- in my 30's
- after age 40

Have you ever participated in a MEDICAL weight loss program in the past?*
- Yes
- No
Which weight loss program and what medications did you take?*
ie. doctors name, clinic name. medications, injections.
I believe the following factors may have contributed to my weight problem:*
Please check all that apply.
- poor dietary choices
- I skip meals, then overeat
- I consume too much sugar (ie. sweet tea, regular soda)
- I eat fast food 2 or more times per week
- lack of structured exercise
- I usually sleep less than 7 hours per night
- I consume too much alcohol
- I quit using tobacco products
- anxiety or depression
- medications or illness
- pregnancy
- hormone imbalance
- I have no idea why I am gaining weight.
Do you currently experience any of the following symptoms?*
- Sugar cravings
- Symptoms of low blood sugar or hypoglycemia
- Frequently wake up feeling hungry
- Skin tags
- Increased facial hair
- Acne
- Increased thirst or urination
- Decreased energy / increased fatigue
- Abnormal periods
- Swelling of extremities
- Frequent constipation
- Excessively dry skin
- Frequent heartburn or reflux
- Recent chest pain
- Heart palpitations
- Increasing or frequent shortness of breath
- None of these
Please check all that apply.
How often do you exercise?*
- hardly ever
- 1-2 times per week
- 3-4 times per week
- 5 or more times per week
Are you allergic to any medications, supplements, latex?*
- Yes
- No
Please list what you are allergic to and what type of reaction you have*
What are you allergic to? Reaction?

ie. Sulfa-throat swells, etc.
Do you regularly take any medications or supplements?*
- Yes
- No
Please list your current medications, supplements and dosages*
Medication or supplement Dosage Times per day
Have you ever had major surgery or been hospitalized?*
- Yes
- No
Please list past major surgeries or hospitalizations*
Surgery or hospitalization Approximate date
Have you ever had an electrocardiogram (EKG)?*
- Yes
- No
Approximate date of last EKG*
Have you ever been told you had abnormalities on an EKG?*
- Yes
- No
Please comment on any EKG abnormalities.*

Family History
Family Medical History*
Do the following illnesses run in your family? (Parents, grandparents, siblings, children only.)
- Heart disease
- Diabetes
- Thyroid disease
- Cancer
- Death before age 50
- Stroke
- Obesity
- I am unsure of my family history
- None of the above
Please give us more detail about family cancers*
Family member Type of cancer
More details about early death*
Family member Cause of death Age at time of death
Which family members have struggled with their weight?*
- Mother
- Father
- Grandparent
- Children
Please select all that apply

Financial and Practice Policies
Do you currently receive Medicare benefits, either due to age or disability?*
- Yes
- No
Agreement To Practice Policies*
- I understand that this Practice does not participate with any government or private medical insurance plans. All fees are due at the time of service. Many clients do utilize their flex spending (FSA) and HSA bank cards. It is the responsibility of the client to follow all IRS guidelines when using these accounts for payment. Fees are listed on our website and are subject to change without notice. Also, please be aware that any dietary products and supplements that are sold from our facilities are carefully selected by our staff. As in any business enterprise, such items are typically sold at a profit. There is never any obligation to purchase products at our facility. We do not participate in any federally sponsored health insurance programs (i.e. Medicare or Medicaid) or commercial insurance plans and we do not submit claims or fill out insurance forms. We do provide receipts at the time of service. Since we do reserve one hour for your initial visit, we do require a deposit of $75 to hold the appointment. This fee is fully refundable so long as written notice to cancel is received with a minimum notice of two business days. While we offer many therapeutic options through our weight loss programs, final determination for prescribing appetite suppressants is based on BMI and/or body fat percentage, patient's medical history and other findings. If you do not qualify for controlled appetite suppressants by regulatory guidelines, you will not be eligible for that particular therapy. We will typically check the North Carolina Controlled Substance Reporting System on any new patient to be sure there is no conflict with patient reported medication history. Any dishonesty or willful omission will disqualify patient from receiving services and no refunds will be offered. By signing below, you attest that the above information is true and complete.
Please type full name to AGREE with Policies above*
Comments
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Medical Weight Loss Program Registration

New Patient Weight Loss Registration

Step 1 of 8

Medical History

Have you ever been diagnosed with the following?

Family History

Social History

Financial and Practice Policies

What are you allergic to?	Reaction?

Medication or supplement	Dosage	Times per day

Surgery or hospitalization	Approximate date

Family member	Type of cancer