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Weight loss program
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Weight loss program
Basic Information
Full Name
*
Date of Birth
*
State of Residence
Tennessee (TN)
Indiana (IN)
Missouri (MO)
Alabama (AL)
Kentucky (KY)
Height
*
Current Weight
*
Weight Loss Goals
Primary goal for weight loss
*
Amount of weight you hope to lose
Have you attempted weight loss before?
Yes
No
Readiness
On a scale of 1–10, how ready are you to commit to a medical weight loss plan?
Willing to make nutrition and lifestyle changes?
Yes
No
Acknowledgment
Acknowledgment
*
I understand eligibility is determined by medical evaluation.
I understand care is provided via virtual visits.
I consent to be contacted regarding next steps.
Submit
