Mississippi Weight Loss Survey

1

How much weight would you like to lose?* This field is required.Select one

20-40 pounds

40-60 pounds

60-80 pounds

80-100 pounds

100+ pounds

2

Have you had success with diet and exercise?* This field is required.Select one

Yes, a good amount

Yes, a small amount

Not really

3

Do you have any of the following medical conditions?* This field is required.Check all that apply and click next

Insulin resistance

Type 1 diabetes

Type 2 diabetes

Hypertension

Pancreatitis

Medullary thyroid cancer

Multiple neoplasia 2

None of the above

5

Do you have any questions about the weight loss injections?* This field is required.Please select all your questions

What will results look like?

How long will it take to see results?

What's the cost?

How many injections will I need?

6

What are the TOP 2 reasons you want to lose weight?* This field is required.Check all that apply and click next

More confidence

I want to feel good about myself

I want to feel better

Feel more attractive

Improve my health

7

What's your name?* This field is required.

First Name

Last Name

8

What's your best email address?* This field is required.

example@example.com

9

Terms and Conditions* This field is required.

10

Please enter your phone number* This field is required.

Please enter a valid phone number.