Wellness Prescreening form

Personal Information

First Name

Last Name

Do you permit us to check for existing patient records in our system?

To help us locate existing patient records, please provide any previous last name(s).

Date of Birth

Age

Location preference for services:

Do you need wheelchair accommodations?

Address

City

State

Zip Code

Email Address

Phone

Alternate Phone

Preferred Method of Contact

Primary Care Physician

Physician Phone

Employer

Insurance Company

Insurance Phone

Insurance Group Number

Insurance ID Number

Are you seeking surgical assistance with weight loss?

Height (ex. 6'-02")

Weight (lbs)

Enter BMI calculation

Have you ever had any type of weight loss surgery in the past?