Request an ITG Consultation First Name * Last Name * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Email Address * Phone Number * Height * Weight * Body Mass Index Weight Loss Goal * New or Existing Patient * Please select “Existing Patient” if seen within the last 12 months. New Patient Existing Patient Primary/Secondary Insurance * Insurance Number * Have you been diagnosed with congestive heart failure within the last two years? Yes No (Please note: this program is not suited for patients who have been diagnosed with congestive heart failure.) Do you have a pacemaker or cardiac device? Yes No Have you had blood work done within the last six months? Yes No From where? Do you have food allergies? Yes No What type? It is required by our physician that you bring your blood work with you to your consultation if you have had it done within the last six months. Please note, some charges may apply when you see our physician based on your insurance.
