New Patient Forms

Below please find forms available to our new patients.

These forms should be downloaded, completed and brought to your first appointment. You may also fax these to your Last Diet Ever location, but you will still need to bring the forms to your first appointment. Please note that if you email these forms to your counselor, email transmission is not considered secure and should only be used to transmit non-confidential information.

Contact Information and Questionnaire

Medical History Form

Financial Policy

Credit Care Financing


Fax numbers:

Avon - 440-934-3428

Mansfield - 419-529-5677

Medina - 330-721-1456

Sandusky - 419-502-0203

Westerville - 614-392-2849