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Application: Patient Information

Please note that by completing the following application, you are applying for the Duke Diet and Fitness Center program. Your application will be reviewed to determine your eligibility for the program. You will receive notification of our decision within two business days after receipt of your application. We ask that you delay making travel or lodging arrangements until after you have received confirmation of your program acceptance. If you are seeking additional information about the program, please contact the Admissions team at 800-235-3853 or at dfcinfo@duke.edu.

At the Duke Diet and Fitness Center we do our best to guarantee a safe environment for all of our clients. Please let us know BEFORE YOU LEAVE HOME if you have travelled to Nigeria, Liberia, Guinea or Sierra Leone in the past three weeks.

Thank you!

I am a ...

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New Client

Return client (within the last 3 years)

Support client

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Legal Name (First and Last)

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Nickname

Gender

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Male

Female

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Date of birth

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E-mail

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Admission date (Mondays for new clients) First choice (mm/dd/yyyy)

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M-D-Y

Second choice

Program length

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5 days

2 weeks

3 weeks

4 weeks

More than 4 weeks

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Please indicate which program length you request (12 weeks maximum)

Home address

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City

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State

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ZIP

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Home phone

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Mobile phone or pager

Occupation

Employer

Work phone

Work E-mail

Where do you prefer to be contacted?

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At home

At work

Other

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Other:

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Marital status

Single

Married/Living with partner

Separated

Divorced

Widowed

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Please indicate that you have read and you understand the Duke Diet and Fitness Center Exercise Tolerance Test policy by typing "yes" in the box. The policy can be found here:

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Emergency Contact

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Phone

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Relationship

Do you have Medicare Part B as your primary insurance?

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Yes

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Please fax a copy of the front and back of all medical insurance cards to us at (919) 688-3295 prior to your arrival. You may require medical services not included in the cost of the Diet & Fitness Center's program fees, such as a stress test.

Primary Insurance Company

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BCBS NC/SEHP

Blue Cross Federal/Out of State

Medicare

Medicaid

UHC

Cigna

Aetna

Duke Employee

Other

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Name of Primary Insurance Company

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Primary policy holder's full name

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Primary policy ID

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Is your primary insurance a...

PPO

HMO

Other

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Primary Insurance Group Number

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Phone number for primary insurance company

* must provide value

Do you have secondary insurance?

Yes

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Secondary Insurance Company

* must provide value

BCBS NC/SEHP

Blue Cross Federal/Out of State

Medicare

Medicaid

UHC

Cigna

Aetna

Duke Employee

Other

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Name of Secondary Insurance Company

* must provide value

Secondary policy holder's full name

* must provide value

Secondary policy ID

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Is your secondary insurance a...

PPO

HMO

Other

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Secondary Insurance Group Number

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Phone number for Secondary insurance company

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