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You Are Just One Step Away From Starting
Your Medical Weight Loss Journey To A
Thinner, Healthier You!
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Watch The Video Below...
Then
Complete The Survey,
So We Can
Personalize Our Medical Weight Loss Services
To Help You Lose The Most Weight &
Revitalize Your Wellness
Complete The Survey Below
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First Name
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Last Name
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Email
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Select...
High School
Trade School
Associates Degree
Bachelors Degree
Masters Degree
Doctorate Degree
Professional Degree (e.g. MD or JD)
What Is Your Highest Level Of Education?
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Single (Never Married)
Married
Divorced
Separated
Widowed
Domestic Partnership
What Is Your Marital Status?
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African American
American Indian
Asian/Pacific Islander
Caucasian
Hispanic American
Which Ethnicity Best Describes You?
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Part-Time Employee
Full-Time Employee
Self-Employed
Military
Unemployed
Retired
What Is Your Employment Status?
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< $50,000
$50,000 to $74,999
$75,000 to $99,999
≥ $100,000
What Is Your Annual Income?
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What Are Your Favorite Foods?
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Daytime
Nighttime
Do You Tend To Eat More During The Day Or Night?
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Yes
No
Have You Noticed A Decrease In Your Concentration Or Memory?
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Yes
No
Do You Crave Carbohydrates?
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Yes
No
Do You Have Problems Sleeping At Night?
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How Many Meals Per Day Do You Eat? (Insert Number)
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How Many Snacks Do You Eat Per Day? (Insert Number)
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Yes
No
Are You An Emotional Eater In Which You Eat When Upset, Angry, Sad, Etc?
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Yes
No
Do You Believe Your Chances For Success Would Increase If You Understood More About Why You Overeat?
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Strongly Agree
Slightly Agree
Agree
Disagree
Strongly Disagree
How Do You Feel About The Following "Changing The Way You Eat Takes Both Mental & Physical Change Of Discipline."
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0%
20%
40%
60%
80%
100%
What Percent Of Successful Weight Management Do You Feel Involves Changing The Way You Think?
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Every Day
More Than Once Per Week
Once Per Week
Once Per Month
Once Per Quarter
Anytime There Is Important Health News
Education Frequency
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Blog Articles
Podcasts
Membership Site With Password Access
Webinars
Video
Media Preferences
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In Person
Telephone
Chat
Email
Videoconference
Preferred Communication
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Desktop or Laptop Computer
Mobile Device/Smartphone
Preferred Device
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Email
Text Messages
Preferred Notification
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$0
$1 to $1,000
$1,001 to $$3,000
$3,001 to $5,000
> $5,000
Healthcare Out-of-Pocket Expenses
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Select...
Credit Or Debit Card
Payment Plan
Other
Pay Preference
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I'm Ready To Start My Medical Weight Loss Journey
In Just A Few weeks,
You'll Start To See Your Fat Melt Away &
The Quality Of Your Life Go Up
Just Submit The Above Form Now
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