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The Williams Way Healthcare Solutions LLC

Weight Loss & Diet Program Agreement

• http://www.thewilliamswayhcs.com
• 601-336-2042

Patient Information

Program Overview:

• Initial consult fee: $85 (diet visit).
• Medication cost: billed separately at discounted pricing and mailed to patient by partner pharmacy, if

clinically appropriate.

• Labs conducted through Labcorp as indicated (see lab list in membership form).
• Follow-up frequency based on selected membership tier (see below).

Payment & Policies:

• Payment accepted by debit/credit card via Stripe on our website. Memberships auto-renew monthly until

canceled in writing (7 days prior).

• No-Show Fee: $50 Late Cancellation (<24 hrs): $25.
• I understand that medication may be withheld if labs or clinical criteria are not met.

Patient Acknowledgment:

I authorize participation in the Weight Loss & Diet Program, acknowledge the consult fee and separate
medication costs, and consent to Labcorp testing and to receive medications by mail when prescribed.Patient Name:Date:

MM slash DD slash YYYY
Signature:Provider:Initial Consult Fee

Price:

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