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

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Social Information

Health Information

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Medical Information

Food Information

What foods did you eat often as a child?

What foods do you eat now?

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Choose Your Program 

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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