Real Results Wellness Clinic, Inc. - Semaglutide (Google)

1

What Are Your Weight Loss Goals?* This field is required.Select all that apply & click NEXT

Lose stubborn weight

Tighten up loose skin

Fit into smaller clothes

Feel comfortable in swim suit

Boost self-confidence

Other

2

What Areas Are You Wanting To Improve?* This field is required.Select all that apply & click NEXT

Abdomen

Back

Glutes/butt

Hips/thighs

Chin/neck

Chest (male)

3

Has Previous Surgical Work Been Done On These Areas?* This field is required.Select one

Yes

No

It's complicated

6

On Those Days, How Rigorous Is Your Activity/Exercise?Select One

Light

Moderate

Intense

8

Any Questions About This Treatment?* This field is required.Select all that apply & click NEXT

What will my results look like?

How long will it take to see results?

What's the cost?

Is there financing available?

How many injections will I need?

Other

9

What Is Your Preferred Payment Method For This Treatment?* This field is required.Select One

Cash

Check

Credit Card

11

Can We Get Your Name?* This field is required.Enter first and last name

First Name

Last Name

12

What's Your Best Email Address?* This field is required.Enter best email address

13

What Is A Good Phone Number To Reach You?* This field is required.Enter your phone number

Area Code

Phone Number

14

Terms and Conditions* This field is required.

15

Sender