Weigh Loss Form

What's your goal?

Loose Weight

Improve Health

Increase Energy

Other

Please select one of the above options*

We can't wait to meet you.

Please fill in the details below so that we can get in contact with you.

Please enter your name

Please fill your Name

Please enter a phone number

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Please enter your email

Please fill your Email

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Let’s start with where you are now

Use the sliders below to calculate your BMI

Your Age

Please fill your Age

Height

1000

Weight

Your BMI

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Are you pregnant, or trying to become pregnant?

Yes!No

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Are you breastfeeding?

Yes!

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Do you have a history of diabetic retinopathy?

Yes!

Please select one of the above fields

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Have you been diagnosed with any conditions involving liver gallbladder or pancreas?

Yes!

Please select one of the above fields

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Have you ever had any thoughts of self harm or severe depression?

Yes!

Please select one of the above fields

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Do you or any member of family have thyroid or pancreas cancer?

Yes!

Please select one of the above fields

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Do you have any history of thyroid disease?

Yes!

Please select one of the above fields

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Have you ever had any organ removed?

Yes!

Please select one of the above fields

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Confirm Submission.

Thanks for taking the time to complete this questionnaire.
Please confirm your email below and we will be in contact within 24 hours.

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What state do you live in?

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What's your best contact email?

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Are you currently on Semaglutide or Tirzepatide?

Yes!No

Please select one of the above fields

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