RedRock WeightLoss Patient Intake
Patient Questionnaire
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Email *
Who were you referred by? *
Do you give us consent to obtain your information solely for the concierge program? (No information will be shared with any other sources.) *
Patient Last Name *
Patient First Name *
Patient Date of Birth *
MM
/
DD
/
YYYY
Address (include city, state & zip code) *
City, State *
Zip Code *
Phone Number *
Are you experiencing any of the following health problems? *
Required
How much do you currently weigh? *
What is your target weight?
If you're experiencing pain check the areas that apply.
On a scale of 1-10 how bad is your pain? *
How long have you experienced pain? *
Do you feel tired or weak? *
List any major health issues and/or surgeries *
What medications are you currently taking? *
Do you have allergies to medications or to food? *
If so, please explain.
You understand that no payment is due at the time of this registration. Completing this form locks in your program fee of $99. A monthly recurring fee of $99 will be charged during the course of your treatment. Treatment plans may be up to 12 months, but is on a case by case basis. With this program you will have access to telemed (virtual) consultation, medical professional concierge, online prescriptions and medication delivery to your home. *
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