Information

NEW PATIENT

CONFIDENTIAL SCHEDULING FORM

First name

Date of Birth:

Last name

Phone Number:

Email Address:

Current location (city and state):

How did you hear about us?

What are your preferred appointment times/days?

Please note: Current counseling hours are Monday, Tuesday, Thursday, and Friday from 7am-3pm PT (closed Saturday-Sunday). We are now scheduling off of a waitlist for new clients, so the more flexible you are in scheduling times, the quicker we can get you started.

Kylie works exclusively in weight management by offering customized plans and counseling.

Please confirm you are seeking weight-loss services:

Please describe your main health goals:

Do you have pre-existing medical conditions?

Height:

Current body weight:

Desired body weight:

Thank you! We will be in touch soon to help schedule your first appointment.