Let’s get started!

1
What’s inspiring you to begin your journey?* This field is required.
I want to lose weight and feel more confident
I want to improve my overall health and wellness
I’m preparing for a special event or milestone
I want to boost my energy and motivation
I’m ready for a lifestyle change
I was inspired by a friend or family member
2
What’s your target weight loss?* This field is required.(Use the slider to set your goal)
Target KG
0
Up to 5 kg – for a light reset
6–10 kg – for noticeable progress
11–20 kg – for a major change
Over 20 kg – for a complete transformation
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Target KG
0
Up to 5 kg – for a light reset
6–10 kg – for noticeable progress
11–20 kg – for a major change
Over 20 kg – for a complete transformation
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
3
What is your current Weight?* This field is required.We’ll calculate your BMI for you.
Weight (kg)
4
What is your current Height?* This field is required.We’ll calculate your BMI for you.
Height (cm)
5
BMI ResultBMI Interpretation BMI < 18.5 → “Underweight” 18.5–24.9 → “Normal” 25–29.9 → “Overweight” ≥30 → “Obese”
6
Where does your body usually gain weight first?* This field is required.
Face / Neck
Arms
Chest / Upper Body
Belly / Midsection
Hips
Thighs / Legs
Overall (evenly distributed)
7
How many hours of sleep do you usually get each night?* This field is required.
Less than 4 hours (very little sleep)
4–5 hours (below average)
6–7 hours (typical amount)
8–9 hours (recommended range)
8–9 hours (recommended range)
8
On average, how high are your daily stress levels?* This field is required.(Use the slider to set your goal)
😇 Not at all stressed
🙂 Slightly stressed
😐 Moderately stressed
😣 Very stressed
😫 Extremely stressed
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😇 Not at all stressed
🙂 Slightly stressed
😐 Moderately stressed
😣 Very stressed
😫 Extremely stressed
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
9
What improvements are you looking forward to during this journey?* This field is required.
Transform my body and mindset
Build a healthier lifestyle I can sustain
Regain control over my health
Feel proud and comfortable in my skin
Develop lifelong healthy habits
10
How old are you?* This field is required.
11
Gender* This field is required.
Female
Male
12
How would you describe your current situation?* This field is required.
I’m currently pregnant
I’m planning to conceive soon
I’m currently breastfeeding
None of these apply to me
13
Metabolic and Hormonal Conditions* This field is required.Do you have or have you been diagnosed with any of the following conditions? (Select all that apply)
None of these apply to me
Thyroid disorder (Hypothyroidism / Hyperthyroidism)
Diabetes (Type 1)
Diabetes (Type 2)
Diabetic ketoacidosis (DKA)
Polycystic Ovary Syndrome (PCOS)
Hypoglycemia (low blood sugar)
Personal or family history of medullary thyroid carcinoma (MTC)
Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)
Metabolic syndrome
14
Digestive and Organ Health* This field is required.Do you have or have you been diagnosed with any of the following conditions? (Select all that apply)
None of these apply to me
Acid reflux (GERD)
Severe gastrointestinal condition (e.g., gastroparesis)
Gastroparesis or delayed digestion
Pancreatic disorder or pancreatitis
Gallbladder disease or history of gallbladder removal
Active gallstones or current gallbladder symptoms
Liver disease (such as fatty liver or cirrhosis)
Kidney disease (Stage 3 or higher)
End-stage renal disease or currently on dialysis
15
Cardiovascular, Respiratory, and Other Health Conditions* This field is required.Do you have or have you been diagnosed with any of the following conditions? (Select all that apply)
None of these apply to me
High blood pressure (hypertension)
High cholesterol or elevated triglycerides
Heart disease or other heart conditions
Sleep apnea or breathing issues during sleep
Osteoarthritis or mobility limitations related to weight
Eating disorder (e.g., anorexia, bulimia, binge eating)
Muscular dystrophy
16
Do you currently use any weight loss products such as pills, teas, injections, or herbal supplements?* This field is required.
YESNO
17
Are you currently on hormonal birth control or hormone replacement therapy?* This field is required.
YESNO
18
Please indicate if you are currently using any of the medications listed below.* This field is required.(Select all that apply)
I do not use any of these medications
Insulin
Glibenclamide / Glyburide
Glimepiride (Amaryl)
Sitagliptin
Saxagliptin
Linagliptin
19
Have you taken any GLP-1 medications within the past 2 months?* This field is required.
No, I haven’t taken any GLP-1 medications recently
Yes – Tirzepatide (e.g., Mounjaro, Zepbound)
Yes – Semaglutide (e.g., Ozempic, Wegovy)
20
Do you have any additional medical conditions, surgical history, or other health concerns we should be informed of?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
21
Name* This field is required.Your full name is collected for record-keeping purposes.
First Name
Last Name
22
Phone Number* This field is required.We’ll only use your details to provide delivery updates or contact you about any order issues we never send spam.
Area Code
Phone Number
23
Terms and Conditions* This field is required.
24
Where would you like us to deliver your treatment?* This field is required.Your location allows us to select the most efficient shipping option and packaging for you. Every order includes free delivery right to your doorstep.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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