For current patients only: Please use this form to order your weekly number of meal replacements for the physician-supervised medical weight loss program. Please call our office at 678-312-6200 with any questions. Thank you!

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1. Date you're attending

Date

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3. Name

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4. Additional comments

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12. Class that you will be attending?

Center for Weight Management
3215 McClure Bridge Road
Duluth, GA 30096
678-312-6200 Phone
678-312-6226 Fax
afalcon@gwinnettmedicalcenter.org

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