



Please fill out this form to be submitted upon your arrival to
the Rice Diet Center. You may type directly on these PDF forms. Please print
the form after you have filled it out, sign it, and bring a copy to the
Rice Diet Center. Feel free to print an additional copy for your
personal records.
If you do not have a copy of
Adobe Acrobat Reader, you may obtain a free copy
here.
Note: Please do not type into the designated
signature field. Sign on the signature line in pen after you
have printed the form.