First name*

Last name*

Your email*

Phone number

How much weight would you want to lose?*

5-10 lbs (2.25-4.5 kg)

10-20 lbs (4.5-9 kg)

20-30 lbs (9-13.5 kg)

30-50 lbs (13.522.75 kg)

50+ lbs (22.75+ kg)

What is your timeline?

1-3 months

3-6 months

6-12 months

12+ months

No specific timeline

What's been your biggest frustration with weight loss?*

On a scale of 1-10, how stressed do you feel daily? 1-2 very, 3-4 low, 5-6 moderate, 7-8 high, 9-10 overwhelming

What weight loss methods have you tried before?

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