NOTE: This form is for patients coming to the clinic for Injections or Weight Loss.
Patients filling out this form must have an appointment already scheduled. (If you do not have an appointment, click Schedule my appointment to make one now). Please fill out this form at least 48 hours prior to your appointment. All fields must be filled out as completely as possible to ensure your chart is set up accurately. Your form will be evaluated by a physician prior to your appointment time and your chart will be active upon arrival to your scheduled appointment. This ensures a better patient experience for you!