Let’s start with where you are now
Date of birth
*
Your height
*
Your current weight
*
Gender at Birth
*
Female
Male
Why do you want to lose weight?
*
To improve overall health.
To feel more confident.
Doctor's recommendation
To increase my energy levels.
Other.
On a scale of 1-10, how important is it for you to achieve your weight loss goal within the next 6 months?
*
1 - not important
2
3
4
5
6
7
8
9
10 - very important
Have you ever tried medical weight loss programs or treatments before?
*
Yes
No
Do you feel like you've done everything possible to lose weight?
*
Yes
No
Considering our program is out-of-pocket, as insurance DOES NOT cover it, how committed are you to invest in your weight loss goals?
*
I'm fully committed and willing to invest.
might need some financial options or a payment plan.
I'm not ready to invest at this time.
First Name
*
Last Name
*
Email
*
Phone
*
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
