Client Forms

Credit Assessment_2

Please complete this form if this is your initial visit or it has been more than 12 months since your last visit. Please make sure all information is accurate, all medications that you are currently taking are listed, and that you sign the form. Failure to complete every section of this form, with accurate health information, may result in denial of medication coverage.

Credit Assessment_2

Authorization of Release of Protected Health Information

We will need the following labs: 

1. Complete metabolic profile (CMP)

2. Complete blood count (CBC)

3. Lipid panel

4. Thyroid level: (TSH/T4) 

5. Diabetes test: (A1c)

Labs must be within the past 12 months.

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Consent for Treatment/Disclosure/Payment Agreement

​The following form is required to be completed by all clients. Download this form, complete it, and bring it to your appointment. 

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Follow-up Weight Loss Visit

Please complete the following form when you are scheduled for a follow-up prescription loss visit or follow-up comprehensive nutritional visit. 

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HIPAA Privacy Notice

Please review the HIPAA privacy notice and sign. 

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If you wish to receive B-12 or lipotropic injections at our facility please read the consent form, print it off, sign it and bring it in during your visit. Click the picture for the PDF version and click the title for the word doc version. 

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Stimulant/

Phentermine Informed Consent

​Please read, initial, and sign this form if you are prescribed phentermine or any other stimulant appetite suppressant.

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Telemedicine Guidelines

Please read the telemedicine guidelines prior to booking your telemedicine appointment. The guidelines will provide information on how to start your telemedicine visit and what is required for your visit.

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Authorization for Photography Video,
Audi0 and/or Interview Use and Release

If you desire to submit your before and after photographs, testimonials, videos, audio-taping, and/or interviews, please read and sign this release. 

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Please read the telemedicine guidelines prior to booking your telemedicine appointment. The guidelines will provide information on how to start your telemedicine visit and what is required for your visit.

Monday: 1:00 pm - 7:00 pm

Tuesday: 9:00 am - 7:00 pm

Wednesday: 9:00 am - 5:00 pm

Thursday: 9:00 am - 5:00 pm

Friday: 9:00 am - 5:00 pm (telemedicine) by prepaid appointment only

Saturday: Closed

Sunday: Closed

1701 Sunset Ave.

Ste. 105-C

Rocky Mount, NC 27804

Office: (252) 969-0432

Fax: 888-977-1275

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©2016 by Anew Weight Loss Center, PLLC.