Weight Loss Program Questionnaire

Please fill out the following to help us determine if you are qualified for our weight loss program. This form will be submitted to our team to review and we'll email you back with your result on whether you're eligible for our program or not. Thank you!
We're currently only accepting patients within New York State
Your BMI calculation will help us to determine you eligibility for our program. Our team will use this data in addition to your other answers in this questionnaire to determine eligibility.

Medical History Related To Weight Management

Select all that apply

Previous Weight Loss Efforts

Family and Personal Medical History

Select all that apply

Additional Comments or Questions

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Vita Drip & Beauty Bar is located at 95 Allens Creek Rd. Suite 238, Building 2.

THE NUMBER 1 DRIP BAR IN ROCHESTER!