Weight Loss Appointment Form Kindly complete the form and one of our experienced weight loss specialists will get in touch with you promptly. Weight Loss FormFull NameEmail IdDate of BirthPhone NumberAppointment DatePreferred TimeHeight (inches)Weight (lbs)Estimated BMISocial Security NumberAddressAre you over 75 years of age? Yes NoHistory of heart disease? Yes NoHistory of heart attack? Yes NoAny stents in the heart? Yes NoHistory of heart surgery? Yes No(If any of the four questions pertaining to their heart is answered with a yes, the patient will need to see a cardiologist for clearance. The patient can have their information faxed to us brfore the visit.)Do you have closed angle glaucoma ? Yes NoDo you carry Passport insurance ? Yes No(If the patient does carry this particular insurance they cannot be seen. We cannot collect a co-payment from them for the visit. Our doctors cannot legally see them.) Appointment will be verified by e-mail or telephone* Not all days and times will be available but every attempt will be made to set your appointment on the preferred date at the preferred time. All appointments will be verified by e-mail or telephone.Submit Your Form