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February 08, 2012

Contact

Weight Loss Solutions
1026 SW 2nd Ave, Suite B
Gainesville, FL 32601

Phone: (352) 665-4786

Fax: (352) 377-5307

Email: WeightLossSolns@yahoo.com

Free Online Consultation

Please fill out the information below for your free online consultation. The information will be reviewed by a physician and you will be contacted within 72 hours.

Your name*:

What is your age*:

Your gender*:

Female
Male

Your phone number*:

Your email address*:

Your Insurance (be specific, i.e. BCBS PPO or BCBS HMO; do not inculde ID number):

Medical History:

Your height*:

Your current weight*:

Your medical history: Please list any current or past medical problems.

Your medications: Please list all current medications, including over the counter products.

Other:

Diet History:

Number of prior diets or weight loss attempts:

Other:

Do you have a history of bulemia, anorexia or other eating disorders?:

Yes
No

Which of our offices would you like to schedule your appointment for?:

Gainesville Office
Ocala Office
Live Oak Office

* Required

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