Intake Form | Rockford Weight Loss

Date *

First Name *

First

Middle Initial

Last Name *

Last

Nickname

Nickname preferred

Date of Birth

Gender *

Male

Female

Social Security Number *

Address *

Address

City

State/Province

Zip/Postal

Country

Home Phone

Cell Phone *

Work Phone

Email *

Occupation *

How did you hear about us? *

Primary Care Physician *

Phone Number *

WOMEN ONLY

Are you now or could you be pregnant?

Yes

No

Allergies:

Medications:

Consent

Confirmation *

I, the undersigned, hereby authorize the staff to perform such services as deemed necessary by the physician to diagnose and treat my condition(s). I understand that I am responsible for all charges which may include legal fee, collection fees or other expenses incurred by the provider in collecting my account. I hereby order all parties to accept a copy of this release and assignment in lieu of the original. This shall remain in effect until revoked by me in writing. I agree and understand there are a limited number of new patients accepted into this program and my supervising Doctor will review my progress and willingness to successfully complete the program. If at any time, it is determined that I am neither willing nor desire to continue with the program, I will voluntarily relinquish my spot in the program. After starting the program, I understand that I am responsible for my success and no refund will be offered.

Patient Signature *

Clear

Date *