Medical Mary's Weight Management Challenge

Medical Mary's Weight Management Challenge
Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Date Your Challenge Begins

Month Day Year
What is your beginning weight?
What is your goal weight?
What is your waistline in Inches?
Have you purchased Medical Mary's Weight Management System? *

Yes No
Do you mind having your face recognized in the images?

Yes No
Upload Before Pictures (These images may be used in future marketing campaigns. Please have someone assist you so your cell phone is not in the picture).

Cancel of
Upload Picture on Scale To Validate Weight

Cancel of
By accepting Mary's challenge you are agreeing to allow Mary to use your photo in future Marketing campaigns. *

Clear
*Goal Weight Must Be Agreed Upon Between Both You and Mary in follow-up Email.
**All participants of this challenge must be on Mary’s weight loss system and remain on the system throughout the challenge to qualify for the $250 product gift card.
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