WEIGHT LOSS FORM

Please complete our online intake form below.

This allows our doctor to review your file and approve you for any prescription deemed safe and appropriate for your weight loss and health needs.

You will be contacted by a specialist after your form has been reviewed.

First Name(Required)

Last Name(Required)

Gender(Required)

Date of Birth(Required)

Email(Required)

Phone No(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name(Required)

Emergency Contact Number(Required)

Emergency Contact Relationship(Required)

Primary Doctor's Name

Primary Doctor's Contact No

What is your weight? (Kg)

What is your height? (cm)

Do you have a personal history with any of the following?

Are you under a doctor's care at the present time?

Yes

Surgeries & Other Hospitalisations

Allergies to Medication

Please list any medications you have known allergies to:

Prescribed Medications

Prescribed Medications, over-the-counter drugs, dietary supplements (include vitamins, inhalers, etc.)

What Types of Caffeine Do You Drink?

Coffee

Tea

Soda

None

How Many Cups/Cans Per Day?

Do You Drink Alcohol?

Yes

Do You Smoke?

Yes

How Many Cigarettes Per Day?

For How Many Years?

Women Only - Are you Pregnant, Trying for Pregnancy, or Breast Feeding?

Yes

Weight History

Are you dieting now?

Yes

If yes, what type of diet?

Rate your fat intake.

Rate your salt intake.

What is the main reason you decided to lose weight?

When did you begin gaining excess weight? Provide reasons if known

What do you think is the main cause of your weight problems?

Describe other weight loss programs or previous diets you have followed or attempted

Is your spouse or partner overweight? If so, by how many Kg's

List any food allergies or foods that you avoid

What foods do you crave more than most others? These are your Passion Foods.

What are your worst food habits?

Do you tend to eat more when you are under a stressful situation?

Yes

Do you think you are currently experiencing a stressful situation or emotional upset in your life?

Yes

If Yes - please explain

What do you feel are your obstacle(s) to successful weight loss?

By adding my name below I do willingly request and consent to the premier weight loss programme. To experience success on this program it is mandatory that I follow the diet protocol explicitly. I understand that there is no warrant or guarantee of results due largely to off-site administration and patient-controlled application. 1. I understand that as part of this program I will be required to complete a Medical History, listen to an orientation of the program where I will be instructed on how to administer the injections myself, or make arrangements to have someone assist me. I understand that initial blood tests may be required in order to rule out any conditions that would disqualify me from the program or require any prior treatment before starting the program. I agree to immediately report any problems that might occur to my counselor or coordinator as well as my Primary Physician during the treatment program. 2. I understand that there could be risks involved, as there are with all medications. Failure to comply with the dosage recommendation and dietary restrictions could the weight loss results. 3. I agree that I am, and will be, under the care of my primary medical provider for all other conditions. I understand that the medical providers who administer weight loss therapies or any program cannot replace my regular Primary Care Physician or General Practitioners or other specialists in Family Medicine or Internal Medicine. 4. I understand that treatments for weight loss are rarely covered by insurance companies. We do not accept or bill insurance for this program. 5. I understand that results may vary and I understand that any requests for a full or partial refund will NOT be honoured. Your prescription is in your individual name and cannot be returned. 6. I have read and understand all of the above statements and conditions and have been informed of potential side effects and risks that may be associated with the diet protocol. I fully understand what I am signing and hereby request and consent to weight-loss treatment. I have disclosed my full medical history and I have been made aware of the benefits, side effects and/or rare possible adverse reactions of various treatments. I acknowledge that all statements provided on these forms, and the Confidential Health History Forms are true and accurate to the best of my knowledge and that my treatments will be based on the information provided herein and if I willingly withhold information, I accept full liability for any consequence that may arise therefrom.

Consent(Required)

Agreement to our terms and conditions

I have read and agree to the content of this consent document

Name

I understand that entering my name above constitutes an electronic signature

This field is for validation purposes and should be left unchanged.