FRDCWeight Loss 240-604-2949

New patient

New Patient Intake

Telehealth visits available — including Saturday and Sunday appointments.

Please bring your insurance card and driver's license to your first visit — we do not collect document photos online.

Full name*

Date of birth*

Phone*

Email*

Home address*

Height (e.g., 5'8")*

Weight (e.g., 210 lb)*

Preferred pharmacy name

e.g., the Sam's Club or pharmacy nearest your home

Preferred pharmacy address

Medical history

DiabetesHigh blood pressureKidney diseaseLiver diseaseOther

Other / notes

Current medications

Marital status

Number of children

Smoker

Insurance provider

Member ID

I confirm this information is accurate and consent to be contacted by FRDC.