Let’s start with where you are now

Date of birth *

Your height *

Your current weight *

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 *

State *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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