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Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Current Weight
Feet
Inches
This is your Current BMI
GLP-1 Average Weight Loss is 17-21%
Have You Used GLP-1 Medicines? Semaglutide/Ozempic OR Tirzepatide/Mounjaro
Yes and It worked great
Yes I have lost Over 30 Pounds already
Not yet I have heard about them and excited to learn more
Not yet Never heard of GLP-1
Other
What is your Weight Loss Goal?
I want to Lose 10-25 Pounds
I want to Lose 25-50 Pounds
I want to Lose 50+ Pounds
I want Help with Anti Aging and Body Sculpting
Other
How Important Is professional Support and Guidance to you in achieving your weight loss goals?
Extremely important I need constant support.
Important but I can manage with occasional guidance.
Somewhat important I prefer to do it mostly on my own
Not important I prefer to rely on my own methods.
Other
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Why is now the right time for you to start a weight loss program?
I have upcoming events or milestones that I want to look and feel my best for.
I am Concerned about my long term Health.
I want to improve my overall fitness and energy levels.
I want to set a healthy example for my family and friends.
Other
Medical Labs Completed (Last 6 months)
I am not sure
I have done a TSH (Thyroid Lab) and/or I have done a Metabolic Panel
No I have not done these labs recently
Other
What is your primary goal for joining a medical weight loss program?
To lose weight quickly and safely.
To improve overall health and well-being.
To gain nutritional guidance and support.
To build sustainable habits for long-term weight management.
Other
How would you describe your current weight management efforts?
I have been trying to lose weight but have had limited success.
I am maintaining my current weight but want to achieve more.
I have not started any weight loss program yet.
I have lost some weight but have struggled to keep it off.
Other
What (%) Do you want to lose?
Current BMI Value (Before Weight Loss)
New BMI Value (After Weight Loss)
New Target Weight
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