Get Standard Weight Loss Program Form - Tucson Women's Center

Filling out the Standard Weight Loss Program Form online is a crucial step for individuals seeking assistance with their weight loss journey. This guide will provide clear, supportive instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the Standard Weight Loss Program Form and open it within your browser or preferred editing tool.
2. Begin by entering today's date in the designated field at the top of the form. This helps keep your records up to date.
3. Fill in your personal information, including your last name, first name, middle initial, complete address, city, state, and zip code.
4. Provide your home and cellular telephone numbers, and indicate whether the office has seen you before. If not, specify how they can reach you.
5. Input your email address along with your date of birth and age as required.
6. Select your patient status by marking the relevant option: married, single, widowed, separated, divorced, or other.
7. Enter your Social Security number, current employment status, and your employer's details if applicable.
8. Complete the emergency contact section with the name, relationship, and contact number of the person you wish to designate.
9. Proceed to the weight loss goals section, outlining your motivations, specific goals, and any deadlines you might have.
10. In the weight history section, specify if you have been overweight in the past and provide relevant details.
11. Describe your current eating habits in the section provided for diet and meal preparation preferences.
12. Check all medical history fields that apply and list any medications or allergies you currently have.
13. Fill out the family history and social history sections to provide a complete picture of your health environment.
14. Review the consent form, ensuring you understand the treatment options and acknowledging the risks associated with weight loss programs.
15. Finally, sign the document at the designated areas for signature, date, and witness, ensuring the form is complete.
16. Once all sections are filled out, save your changes, then download, print, or share the form as needed.

Complete your Standard Weight Loss Program Form online today to embark on your weight loss journey with the Tucson Women’s Center!