Lasting Impression Medical Aesthetics - See if I'm a candidate

1

What is your current weight loss goal?* This field is required.

Lose 5-10 pounds

Lose 10-20 pounds

Lose 20-50 pounds

Lose more than 50 pounds

2

How committed are you to reaching your weight loss goal?* This field is required.

Very committed

Somewhat committed

Not very committed

Not at all committed

3

Have you tried to lose weight in the past?* This field is required.

Yes, I have tried several times

Yes, I have tried once or twice

No, I haven't tried

4

Have you ever heard of Injectable Weight Loss before?* This field is required.

Yes, I have heard of it

No, I haven't heard of it

5

How do you feel about taking medication to help with weight loss?* This field is required.

I am comfortable with it

I am hesitant but willing to try

I am not comfortable with it

6

How important is it for you to lose weight?* This field is required.

Extremely important

Very important

Somewhat important

Not very important

7

Have you ever been diagnosed with a medical condition that affects your weight?* This field is required.

YESNO

8

Do you follow a healthy diet?* This field is required.

Yes, I follow a healthy diet regularly

Yes, I try to follow a healthy diet

No, I don't follow a healthy diet

9

Do you exercise regularly?* This field is required.

Yes, I exercise regularly

Yes, I try to exercise regularly

No, I don't exercise regularly

10

Do you have any food allergies or sensitivities?* This field is required.

Yes, I have food allergies or sensitivities

No, I don't have food allergies or sensitivities

11

Date of Birth* This field is required.

Date

12

Full Name* This field is required.

First Name

Last Name

13

Email Address* This field is required.

example@example.com

14

Phone Number* This field is required.

15

What's the best way for us to get in touch?* This field is required.

Phone call

Text message