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For Appointments 843-792-2273

Midlands Appts. 803-865-4650

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843-792-2273
wmc@musc.edu
1122 Chuck Dawley Boulevard
Building B
Mount Pleasant, SC 29464

Voted Best Weight Loss Center in Charleston 3rd year in a row

Register for the Jump-Start Program

Name

First

Middle

Maiden

Last

Address

Street

City

State

Zip Code

Phone & Email

Cell Phone

999-999-9999

Home Phone

999-999-9999

Work Phone

999-999-9999

Email

Date of Birth

Sex

Race

Occupation

Employer

Do you have diabetes?

Yes
No

Do you have any exercise restrictions?

YesNo

Do you have a history of eating disorders?

YesNo

Based on your past weight control experiences, what challenges have you had that you would like help with during this program?

In addition to a change in the number on the scale, what benefits do you hope to gain from weight loss?

Have you ever been a patient with the MUSC Weight Management Center?

YesNo

Are you a MUSC/MUHA/MUSCP employee or spouse that will be paying by payroll deduction?

YesNo

General MUSC Health Line 843-792-1414

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