Golden West Medical Center
Tucson, Arizona
(520) 792-1966

Medically Supervised Weight Loss in Tucson, Arizona
 
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Tid Bits: Bananas are a good source of vitamin C, potassium, and dietary fiber.

  Request an Appointment Online


Please feel free to use this form to request an appointment online. The information that you provide here is only used in regards to your appointment and is not used for other purposes.

Our staff will contact you as soon as possible to confirm your appointment and answer any questions that you may have. Unless you indicate otherwise, we will attempt to leave a message for you if you are not in when we call. If you provided an email address, you will automatically receive a copy of your request and we will email a confirmation of the actual scheduled appointment instead of calling by telephone.

Please Note: Your appointment is not considered scheduled until we have confirmed it with you by telephone or email.

Patient Name:First:         Last:
Patient is a New Patient       Existing Patient
 
Please Note: New (NEVER been here) patients require more time for their first visit so the range of appointment times is limited. We will confirm your request as soon as possible. If you have ever been seen in this office you must select "Existing Patient".
 
To properly identify you in our records we need one of the following items:
Patient Date of Birth: (MMDDYY or MMDDYYYY)
OR
Patient Chart Number: (Located on your medication bottles)
Phone Number:
Email Address: (to send confirmations)
Time Requested:
Date Requested:
Day:       Month:       Year:
Appointment Type: Weight Loss       Other Appointment Type (Describe appointment below)
 
Describe Appointment:
Provider You Prefer: (You may see any provider here that you like.)
* If no provider preference is given you will be scheduled with any of our providers.
Other Comments:



Thursday, April 24, 2014