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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
How Often do You Check Your Email?
Every Few Hours
Daily
Every Few Days
Weekly
Monthly
Rarely
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Would you like your weight to be different?
Yes
No
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Social Information
Health Information
Do you still have a gallbladder?
Yes
No
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Are you pregnant?
Yes
No
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Are you breastfeeding
Yes
No
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Medical Information
Food Information
What foods did you eat often as a child?
What foods do you eat now?
Will family and/or friends be supportive of your desire to make food/lifestyle changes?
Yes
No
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Do you cook?
Yes
No
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Choose Your Program
Choose Your Program
Basic hCG Program $499.00
Platinum Keto/hcg Program $1499.00
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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
Photo of Driver's License
Max File Size 15MB
SUBMIT FORM
Thank You
