 Patient Documents
 Weight Loss Institute of Arizona kindly
requests all patients download, print, and fill out all patient documents
prior to your first office visit.Thanks!
Click Here to download Patient Information Form |
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| Download all new patient WLIAZ medical forms |
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Request for Insurance Verification
This form allows our Insurance Specialist Ronda to contact your insurance company and employer on your behalf to determine your benefits and coverage. This form is required to make a first appointment even if you do not have insurance. When you come to your first appointment we will go over a detailed invoice based on your insurance. This is a free service. |
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Program Enrollment Price List and Appointment Cancellation Form
This form has two different components. The first is to disclose some of the costs that typically are not covered by insurance. The second is our cancellation policy. Because your appointment can be up to a three hours, we request that you cancel or change your time within 24 hours so we can schedule other patients. There is no charge for your appointment until you decide to move forward with our services after meeting with the financial specialist. This credit card information will only be used if you do not keep your appointment and you can not be reached; it is not used for payment of services. |
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New Patient Information Form
This form allows the medical staff to review your medical and diet history. |
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Request and Release for Medical Records
This form allows you to get a copy of your medical records. Normally, insurance companies require five years of medical records to consider granting coverage for weight loss surgery. Our office is happy to request your records, however, it is often most expedient for patients to request their own records in person. Use this form to request documents from all medical facilities that you have received treatment from in the past five years.You should also get the records from all diet centers and personal trainers attended during the past five years. |
