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: ______________________