To better help you, please tell us more about your goals
 

How many pounds do you want to lose? (check all that apply)

0-10
10-20
20-30
30 PLUS

What have you tried in the past to lose weight? (check all that apply)

Exercise
Surgery
Diet
Pills
Other

 

On a scale of 1-10 (10 being greatest), how important is it for you to lose weight?
10
9
8
7
6
5
4
3
2
1

What age group are you in?
Under 20
20 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 plus



Title:

First Name:

Last Name:

Address 1:

Address 2:

City/Town:

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Zip/Postal Code:

Country:

Best phone number at which to reach you:

Best time to be contacted at the number provided:

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