Bodiwell Wellness and Weight Loss – Patient Intake Form

Welcome to Bodiwell Wellness and Weight Loss!

We are dedicated to helping you achieve safe, sustainable, and long-lasting health results through personalized plans, expert guidance, and comprehensive care. Please fill out the details below completely and accurately so we can design a program that fits your needs, health history, and goals. All information you share is kept strictly confidential.

We’re excited to support you every step of your wellness journey!

First Name *

Last Name *

Phone *

Email *

Address

Street Address

City

State

Country

Postal Code

Date of birth *

Personal ID Front Picture:

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Personal ID Back Picture:

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Insurance Information:

Carrier:

Insurance ID front picture:

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Insurance ID back picture:

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Co-Pay Insurance:

Medical Diagnoses: *

Medications: *

Allergies: *

Current Weight: *

Current Height: *

Have you tried any weight loss medications before? *

Goal Weight? *

Thank you for completing your intake form! 🤍

At Bodiwell Wellness and Weight Loss, every detail you share helps us create a safe, personalized plan designed just for you. Our team is already looking forward to reviewing your information and guiding you toward your health and wellness goals.

We will reach out to you shortly to schedule your consultation. If you have any questions in the meantime, feel free to message or call us.

Let’s start your journey to a healthier, happier you, together! ✨

— The Bodiwell Wellness and Weight Loss Team

For all insurance patients or if you prefer an appointment directly with the provider, we kindly invite you to schedule an appointment.

New patients are required to schedule 1st appointment with provider.

I hereby consent to receive non‑marketing text communications from Bodiwell Wellness & Weight Loss concerning health services and consultation matters. Carrier fees and message limits may apply. Reply STOP to unsubscribe or HELP for further information.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Bodiwell Wellness & Weight Loss at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.