By filling out this form, you certify that all health information, medical history, medication history, allergies, and other responses you provide are accurate, complete, and truthful to the best of your knowledge. You understand that this information will be relied upon by WeightWise Medical Clinic P.C. and its medical providers to evaluate your eligibility for treatment and make clinical decisions. You acknowledge that incomplete, inaccurate, or false information may result in delayed care, denial of treatment, inappropriate prescribing, or potential harm to your health.
