Weight Loss Program Registration Form
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1Weight Loss Program Registration Form
DEMOGRAPHICS:
Date:___________
Full Name:
Social Security #:
Date of Birth:
Gender:
____ M _____ F
Marital Status: _____________
Address:
Apt#.:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Emergency Contact Name:
Phone #:
E- mail:
How did you hear about us?
HISTORY:
Any History/Current Medical Illness?
______ Y es _______ No
If Yes, please check if applicable:
Heart Disease
Hypertension/High BP
Blood Disease
Stroke/Aneurysm
Diabetes
Cancer
Other:
List Current Medications
Are you allergic to any medications?
_______ Yes _____ No
If yes, please list them below:If yes, please list them below:
What is your ideal weight?
____________ lbs.
What weight loss program have you decided to register in? (please check program desired)
MEDICATION PROGRAM *
*CASH
HCG 26 Day Program
*WITH INSURANCE
HCG 43 Day Program
INSURANCE NAME:
ID #:
Family Doctors of Green Valley
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Parent category: Business