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Weight Loss Management Intake Form & Financial Agreement

This form is to be completed ONLY if you have not yet been seen here for weight loss management services.

Birthday
Month
Day
Year
Gender
Which medication are you using?
Have you experienced any of the following side effects? (check all that apply)
Have you missed any doses?
Have you changed your diet since your last visit?
Have you changed your exercise frequency and/or duration since your last visit?
Have there been any changes to your sleep habits?
Have there been able to manage your stress normally?
On a scale of 1 to 10, where 1 is "not satisfied at all" and 10 is "completely satisfied", how would you rate your progress so far?
What outcome would you like to see as a result of this appointment?

Your signature below indicates that you have provided the most accurate health information to the best of your knowledge. Solutions Med Spa will not be responsible for errors that occur when information is incomplete or inaccurate.

What's Next?

Our staff will review your intake form as soon as possible, and we will reach out to you using the contact information provided above. At most, we anticipate a single business day turnaround time.

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