Enrollment Forms

Welcome to the Institute of Lifestyle & Weight Management! The Institute is a place to help you lose weight, get healthy, get fit, and reclaim the lost "you." Studies show that the only effective way to lose weight and keep it off permanently is to change your lifestyle and to eliminate detrimental behaviors. Even though you may have failed in the past or managed to lose weight only to gain it back, ILWM is the answer for several reasons. What makes us different? The Institute of Lifestyle & Weight Management is a medically based integrated model with a healthcare team composed of physicians, dieticians, and exercise physiologists. Our strong support team will be with you every step of the way helping you make those critical lifestyle changes.

Before you come in for your initial visit, please take a few moments to fill out the following enrollment forms:

ILWM Enrollment Forms - Download PDF

ILWM Adult Health Assessment - Download PDF

ILWM Pediatric Health Assessment - Download PDF

ILWM Financial Aid Form - Download PDF
(ILWM does not discount for its services; however, we will strongly consider requests for financial aid. If you need financial aid, please download and complete this form)

Please include all of the following information:

1. Contact Information
2. Flex Contract - If you have a Flex Spending or a Health Savings card, and would like to use it towards your membership and monthly payments please fill out your information on this form.
3. Financial Pre-Authorized Checking Form
4. Waiver of Liability & Assumption of Risk
5. HIPAA: Notice of Privacy Practices
6. Acknowledgement of Receipt of Notice of Privacy Practices
7. Authorization for Disclosure of protected Health Information

Membership Fee: During the initial visit, you can pay for the membership fee either by credit, debit, cash, or a check payable to 'ILWM'.

Monthly Fee: The monthly fee will be withdrawn from your checking account on the 19th of every month. To set this up, please bring a check made payable to 'CapStat' for the amount of $5.00

If you have any questions, please contact Kaitlin Kovary

The Institute of Lifestyle & Weight Management
3100 Duraleigh Road, Suite 200
Raleigh, NC 27612