New Patient Form URLThis field is for validation purposes and should be left unchanged.Patient Information:Name:(Required) First Last Date of Birth:(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone:(Required)Email Address:(Required) Would you like to receive text messages from Sands Weight Loss and Wellness regarding appointment information, weight management, and medication delivery?(Required) Yes No Text message and data rates may apply depending on your mobile carrier and phone. Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Weight (LBS):(Required)Height (Feet):(Required)Please enter a number from 3 to 8.Height (Inches):(Required)Please enter a number from 0 to 11.Please check if you have a history of any of the following: Thyroid Cancer Endocrine Neoplasia Pancreatitis Current or Planned Pregnancy Currently breastfeeding Retinopathy Suicidal Ideation Crohn's Disease Ulcerative Colitis Type 1 Diabetes Any type of cancer in the last five years Immune Deficiency Disorder None Current Medications:(Required)Do you currently take any medications that affect your blood sugar?(Required)Primary Care Provider (PCP):(Required)PCP Phone Number:When did you last see your PCP?(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do we have permission to reach out to your PCP?(Required) Yes No How did you hear about us?Referring Provider:IF YOU ARE CURRENTLY TAKING SEMAGLUTIDE OR TIRZEPATIDE OR HAVE TAKEN IT WITHIN THE LAST 30 DAYS, PLEASE UPLOAD AN IMAGE OF YOUR PRESCRIPTION IN ORDER TO AVOID STARTING OVER ON THE LOWEST DOSEImage of PrescriptionAccepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 256 MB. CAPTCHA Phone Number 888-726-3795 Hours Monday-Friday 9am – 5pmSaturday 9am – 1pm Address 2300 Lakeview Parkway, 7th Floor Alpharetta, GA 30009