Preferred Appointment Day/Time *

Do you have active medical insurance? *

Yes

No

Self-Pay Notice

Type of Insurance *

Upload Insurance Card – Front & Back *

Upload Insurance Card – Front & Back

Name of Policyholder *

What are your current weight loss goals?

Have you tried any of the following?

GLP-1 medications (Ozempic, Wegovy)

Meal programs (Nutrisystem, Jenny Craig)

Fitness coaching

Other: _______

Have you been diagnosed with Diabetes? *

Yes

No

List current diabetes medications *

Had a Hemoglobin A1C test in the last 12 months? *

Yes

No

Not Sure

Upload result or enter result *

Upload result or enter result

I confirm that the above information is accurate.

I agree to be contacted by Oasis Medical Group for appointment scheduling.