New Patient | Memorial Wellness Center

Before Your First Visit

We want to get to know you and learn how we can assist with your health goals. You will need a referral from your primary care physician, which we can obtain for you. We ask that you complete the pre-screening form so that we can understand your preferences, obtain the referral and obtain your insurance quote. Our insurance team will verify your benefits and send you a quote outlining the price of services. Once these steps are complete, we will contact you to schedule your first appointment.

Our physician-led, multidisciplinary team is committed to working alongside you and your referring physician. In addition to the benefits you will experience by obtaining a healthful weight, you’ll also benefit from the expertise of medical, surgical, lifestyle, physical therapy and nutrition specialists. We are dedicated to providing support and education to improve your health and life—not just your physical appearance. Appointments may include:

Diagnostic testing such as a laboratory work-up, EKG, sleep study and cancer screenings

Lifestyle assessment to identify specific barriers to weight loss and provide appropriate self-management tools to monitor progress and develop healthy coping skills

Nutrition assessment to gauge current nutritional health, metabolism and body composition

Physical assessment of heart health, muscle strength, flexibility, mobility and balance

Diabetes education to learn the seven principles to managing your diabetes

Group education to provide necessary skills for success with weight loss and weight maintenance

Medications for weight loss (if indicated)

Weight loss surgery (if indicated)

Support groups

Based on the findings, you and your team will develop a customized treatment plan to address your needs and health goals.

Your team will monitor the following during your journey with the Memorial Wellness Center:

Effectiveness of your personalized treatment plan

Personal satisfaction with your progress

Health status

Quality of life improvement

Get Started

Complete this pre-screening application.

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:

Decatur Memorial Hospital
Jacksonville Memorial Hospital
Lincoln Memorial Hospital
Springfield Memorial Hospital
Taylorville Memorial Hospital

Do you need wheelchair accommodations?

Contact Information

Address

City

State

Zip Code

Email Address

Phone

Alternate Phone

Preferred Method of Contact

Email
Phone
Text Message (Please save 88286 to your contacts.)

Physician & Insurance Information

Primary Care Physician

Physician Phone

Employer

Insurance Company

Insurance Phone

Insurance Group Number

Insurance ID Number

Medical Information

Are you seeking surgical assistance with weight loss?

Height (ex. 6'-02")

Weight (lbs)

Calculate your BMI

Enter BMI calculation

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

The first step is to attend our Bariatric 101 class, which will outline what you can expect. This class is offered every Thursday from 1 to 2:30 p.m. both virtually and in person. We ask that one of your first appointments be in person. This can be either the 101 class or your new patient clinic visit. We will send a text reminder of this appointment when it is scheduled. Please save 88286 as a contact to your phone so you know it is the Wellness Center contacting you. We will email you a link and instructions to sign up for this class.