Diabetic Weight Loss Patient Information
Our medically supervised weight loss program will help you lose weight and change your diet which will
greatly benefit your efforts to manage your diabetes. It will be up to you and your diabetes specialist (primary
care physician or endocrinologist) to continue managing your diabetes and blood sugar in the process of
losing weight.
We may contact your diabetes specialist to let them know of our efforts in assisting you with your weight
loss or for obtaining medical clearance if deemed necessary.
Please complete the following:
Type of diabetes: Type 1: __________ Type 2: __________
Current medications and dosage for diabetes management: ______________________________________
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Diabetes Specialist name: ______________________________________________________________
Phone number: ________________________________
Fax number: ___________________________________
Patient's Signature: _____________________________________ Date: ______________________