Pre-Qualifying Form
Please answer ALL questions. Write N/A if the question is not applicable to you. All of your information will remain confidential between you and the Sun Valley Medical Weight Loss Clinic.
Personal Information
Social Information
Health Information
Medical Information
Food Information
What foods did you eat often as a child?
What foods do you eat now?
Choose Your Program
Additional Comments
Referred or Inspired
Were you referred or inspired to do the program by someone? If so, who?
Uploads
Driver's license is required for the prescription
