Summit Wellness Patient Intake

Please fill out this intake form to provide us with essential information about your health goals, dietary history, and medical background. This information will help us tailor our wellness strategies to meet your individual needs effectively.

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Height

Weight

Your goals and/or reason for visit:

Nutrition and weight related history :

(ie, any previous diet programs followed, previous nutrition education, weight management medications or procedures, etc.)

Past medical history:

Food related allergies or intolerances:

Phone: (385) 345-3560 Fax: (877) 331-0467

Monday - Friday 9:00am - 4:00pm

Request appointment

LEHI OFFICE:

3000 Triumph Blvd.
Lehi, Utah 84043

(Neurosurgery, Suite 240) (Orthopedic Surgery, Suite 330) (Spine Management, Suite 110)

PAYSON OFFICE:

15 South 1000 East Suite 100 Payson, Utah 84651

PROVO OFFICE:

1055 North 300 West Suite 300
Provo, Utah 84604

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