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Patient Registration

Non-surgical medical weight management

EXPRESS WEIGHT LOSS CLINIC

Patient Registration

Location

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New Patient Registration Form

Patient Name *
Date of Birth *
Gender *
Were you referred to Express Weight Loss Clinic by another Patient? *
If you wish to receive any information or promotions from Express Weight Loss Clinic: *

Medical History

Current/Past Medical History - Check all that apply: *
Heart Attack Date *
Stroke Date *
Past Surgical History - Check all that apply: *
Social History - Check all that apply: *
Review of Symptoms - Check all that apply: *
Eating Habits - Check all that apply: *
Physical Activity - Check if applicable:
Acknowledgement: *
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Patient's Printed Name *
I am 18 years of age or older *

By signing below, I do hereby consent to any medical care and/or treatment administered by the clinician(s) at Express Weight Loss Clinic (EWLC). I understand that EWLC, as well as other clinicians, cannot anticipate whether my child will experience adverse reactions, side effects, or allergic reactions, after receiving any medication(s) EWLC prescribes or administers via injections. I understand that such reactions can occur to anyone, with any medication, at any time, and that the prescribing clinician and EWLC is not at fault for such reactions. I understand that if my child experiences any adverse reactions, side effects, or allergic reactions from any medication(s) that they receive from EWLC, then it is my responsibility to discontinue my child's use of the medication immediately, seek advice, and to have my child evaluated by their PCP and/or Emergency Medical Providers. In the event that my child experiences a medical emergency while being treated at EWLC, I consent to the administration of medical life saving measures determined by the clinician to be necessary for the welfare of my child, while waiting for Emergency Medical Services to arrive on scene during said emergency.

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Guardian's Printed Name *

Thank you for completing the Patient Registration. Click submit below to be routed to our forms page.

Downloadable versions of our forms can be found directly on our Forms Page