Golden West Weight Loss
Tucson, Arizona
(520) 792-1966

Changing the Shape of Tucson since 1984
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Tid Bits: American's spend over 50 billion dollars on diet-related products each year!

  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 it is very helpful if you happen to know your chart number:
Patient Chart Number: (Located on your medication bottles)
Patient Date of Birth: (MMDDYY or MMDDYYYY)
Phone Number:
Email Address: (to send confirmations and instructions)
Time Requested:
Date Requested:
Day:       Month:       Year: (Online requests must be made at least 2 days in advance.)
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 can be scheduled with any of our providers.
Other Comments:

Sunday, July 21, 2024