New Patient Form

Only virtual and in-person assessments. No wait times, get an appointment quickly! Click here

November Special - Men & Women | Tirzepatide & Semaglutide | NAD+ Therapy, Lipo Skinny, B12 Vitamin, Glutathione | Now Available 4 Therapy by Appointment Only Click here

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About Us
Services
FAQ’s
Prices/Plans
Specials
Resources
Contact
Forms

Contact Us

Only virtual and in-person assessments. No wait times, get an appointment quickly! Click here

Contact For the referral

November Special - Men & Women | Tirzepatide & Semaglutide | NAD+ Therapy, Lipo Skinny, B12 Vitamin, Glutathione | Now Available 4 Therapy by Appointment Only Click here

Home
About Us
Services
FAQ’s
Prices/Plans
Specials
Resources
Contact
Forms

Menu

Home
About Us
Services
FAQ’s
Prices/Plans
Specials
Resources
Contact
Forms

New Patient Form

Patient Name

Last Name

Date Of Birth

What is your gender?

Weight

Height (inches)

Goal Weight

Address

City

State

Zipcode

Phone Number

Email Address

HAVE YOU HAD ANY OF THE FOLLOWING? Heart TroubleHigh Blood PressureDiabetesHigh CholesterolShortness of Breath at RestPhenylketonuria(PKU)PalpitationsPersonal or Family History of CancerDiabetic Ketoacidosis(DKA)GlaucomaDizzinessFrequent HeadachesFibroids/CystsOn Any Hormone Replacement Therapy (HRT/BHRT)HIVAnxiety/DepressionFatigueGallbladder IssuesCancerDifficulty SleepingHep B or Hep CDVT/Blood ClotsThyroid IssuesRegularly Suffer from Bowel Issues/Constipation/IBS/Severe Bloating/GERD/ETCLeg CrampsEpilepsy/SeizuresIrregular MenstruationReproductive Organ ProblemsKidney TroubleNone of the AboveOther

List Any Known Allergies

Are you currently taking any Medication and/or Supplements? YesNo

Please list them

Do you use tobacco products?

History of Substance Abuse?

How often do you consume alcohol? DailyWeeklyMonthlyOccassionallyNever

Have you ever been on a Weight Loss Program before?

Do you Excercise?

If Yes, How often do you excersise?

Do you drink: CoffeeSodaEnergy drinksNone of the Above

Do you: Crave SweetsCrave CarbsCrave SaltEat out often

Do you exhibit any of the possible hormone imbalances? Low LibidoHot Flashes or Night SweatsMood Swings, Anxiety, or DepressionExcessive Hair Growth or Hair LossNone of the Above

Emergency Contact

Last Name

Phone

How did you hear about us?

Welcome to Laveen Medical Weight Loss & Wellness, your dedicated partner on the journey to a healthier, happier you.

Services

Weight Loss Medications
Weight Loss Injections
Oral Weight Loss Medications
Weight Loss Supplements

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Direct: (602) 899-7702
Toll Free: 1 (844) 921 2696

4920 W baseline rd. Suite C109
Laveen. Az 85339