New Patient

Forms

For Referrals

There are three options for submitting a referral.

  1. Take in the Physician Referral Form to your primary care physician at your appointment. Your physician will complete the form and submit it our our office.
  2. Your physician can use the link at the bottom of this website for Refer a Patient. our physician will complete the form and submit it our our office. 
  3. Ask your physician to contact Memorial Weight Loss and Wellness Center directly.

Download Referral Form

For Intake Forms

The intake form should be completed prior to treatment. Download either a PDF or Word document, complete the form and fax to our office at 217-527-3209.

Download PDF

Download Word Document