This registration form is ONLY intended for patients enrolling in a Henry Ford Weight Management Program.

Your registration will be reviewed and your account will be activated upon verification of eligibility, entitling you to the following benefits:

• FREE Shipping on orders over $69!
• Discounts on ALL Product Purchases
• Points & Rewards Loyalty Program
• Extended Program Services
  • Exclusive HFHS Weight Management Program Content
  • Virtual Access to Program and Product Support

Weight Management Program

Profile Information

required to create your private account

Name *

First

Last

Username *

please choose your unique username

Password *

Email *

Permission to email

• I will accept your email messages

Phone *

Permission to text

• I accept text messages at this phone number

Treatment Plan Details

Please record the meal plan prescribed by your healthcare provider.

Daily Calorie Target

Total daily caloric intake (in calories)

Daily Meal Replacements

Prescribed number of betterMD meal replacements per day

Additional Recommendations

• Eat one nutrition bar daily
• Add a daily multivitamin
• Add a portion-controlled meal

Calorie target for portion-controlled meal

Location

• Downtown Detroit
• Livonia
• West Bloomfield
• Wyandotte

Special Notes

Was a Sample Kit Purchased? *

• Yes
• No

Please indicate whether or not this patient purchased a Starter Kit.

Consent to storage of information *

• I consent to the storage of this information for the administration of my membership benefits.

Consent to share Information *

• I authorize betterMD to share my personal information with HFHS program staff.

Website

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