New Patient Inquiry

Patient's Legal Name *

First Name

Last Name

Parent or Legal Guardian's Name

If the appointment is for a child or teen (ages 0-17) or for an adult with a legal guardian

First Name

Last Name

Patient's Date of Birth

Please fill out If you would like us to verify insurance coverage for our services

MM

DD

YYYY

Patient's Phone Number *

Parent's phone number for pediatric patients

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Alternative Phone Number

(###)

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Have you been diagnosed with any of the following?

This is optional, however it will help us to navigate the insurance verification process more efficiently

Overweight or Obesity

Type 2 Diabetes

Prediabetes

Heart Disease or Hypertension

Kidney Disease

Type 1 Diabetes

Eating Disorder

Other

How Did You Hear About Us?

Internet Search

My Doctor

Friend or Family Member

Other

Best Time To Reach You

Morning

Afternoon

Evening

Anytime

Preferred Method of Contact *

Please check all that apply

Call

Text

Email

Do You Prefer Virtual or In-Person Appointments?

No Preference

Virtual

In-Person

Are You Interested in Our Group Programs?

Yes

No

Unsure

Health Insurance Provider Services Phone Number

To expedite the insurance verification process, please include the telephone number for Provider Services, which is typically listed on the back of your insurance card

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