Venture Medical Weight Loss List
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11VENTURE
MEDICAL WEIGHT LOSS
Welcome To Venture Medical Weight Loss!
Please Answer the Following Questions
So We Can Better Assist Your Health-care Needs
No need to be intimidated by the length of these intake forms. Many are simply check-marking information
and reading and signing the consents. More importantly, they are required only once every 3 years!
Today’s Date: ___________________
PATIENT INFORMATION (Please Print)
Name: ___________________________________________________
DOB: _____________
(Last)
(First)
(MI)
mm/dd/yyyy
Address___________________________________________________________________
City________________________________ State _____________ Zip Code____________
Social Security #________________________________
(needed for reporting Prescriptions to KASPER = KY All Controlled Substance Patient Electronic Record)
Phone# (Home:)__________________________________ (Mobile:)_____________________
Marital Status: Single / Married / Divorced / Widowed / Separated Please Circle: M / F
Primary Care Physician: ________________________________ Phone#________________________
Employer and Occupation: __________________________________________________________
Emergency contact, name, relation, and number: ___________________________________________
_____________________________________________________________________________
My expectations from this program: _____________________________________________________
Anything you did not like at other similar clinics you have been to, and Venture should try to avoid?
___________________________________________________________________________________
Reviewed by VMWL Staff (initials)___________
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Parent category: Medical