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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2. Are you a Northside Hospital Employee?

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3. Name

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4. Additional comments

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5. Reducing Phase (choose number of boxes below)

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6. Adapting Phase VLCD (choose number of boxes below)

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7. Adapting Phase LCD (choose number of boxes below)

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8. LCD 900/1000

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9. BEVERAGES

  Number of Boxes
Chocolate Drink with Fiber**
Chocolate Drink without Fiber
Vanilla Drink with Fiber**
Vanilla Drink without Fiber
Strawberry Beverage
Pineapple Apricot Beverage
Hot Chocolate ~~
Mocha Beverage**
Berry Smoothie
Variety Pack - Cold (** = 1 sample)

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10. SOUPS AND PUDDINGS

  Number of Boxes
Chocolate Pudding**
Vanilla Pudding**
Lemon Pudding with Fiber
Broccoli Cheddar Soup
Chicken Soup~~
Tomato Soup
Chocolate Mint Pudding and Shake**
Tortilla Soup ~~
Chocolate Salted Caramel Pudding and Shake**
Variety Pack Hot (~~ = 2 samples ) +1 Broccoli

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11. PROTEIN BARS (2 BARS= 1 MEAL REPLACEMENT)    7 BARS IN ONE BOX

  Number of Boxes
Chocolate Fudge Bar (available after 6 week program)
Peanut Butter Bar (available after 6 week program)

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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
Andrea.Falcon@northside.com
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