FREE Weight Control Consultation

Please answer each of the questions listed below (remember, honesty is the best policy). Please include the best contact phone number for you so that my staff can schedule your FREE consultation. If you would like to upload a photo of yourself for me to see, you can do so at the end of the questionnaire.

What is your name? *

Please enter your full name below.

What is your email address? *

Fill in your email address below to receive our recommendations.

What is your telephone number? *

Fill in your telephone number so we can arrange your consultation.

What is your primary area of concern? *

Select all that apply.

Hips and Thighs
Buttocks
Stomach
Legs
Back
Chest
Arms
Chin and Neck
Entire Body

Describe your body shape. *

Choose which body shape best describes you.

I tend to store fat around my stomach and chest - Apple Shape
I tend to store fat in my lower body - hips, buttocks, saddlebags - Pear Shape
I tend to gain and lose fat evenly - Proportionate Shape

What is your body shaping goal? *

Choose the answer that best applies.

Tell me about your workout routine. *

How frequently do you exercise?

What is your current weight? *

Please fill in your answer in pounds.

What is your height? *

Please fill in your height in feet and inches e.g. 5' 7''.

What is your age? *

Please fill in your age and birthday and you will receive a special gift on your big day!

What is your weight loss goal? *

Have you tried a weight loss program in the past? *

Yes
No

If you answered yes to the question above, which program in the past did you try?

Please fill in the name of the program below.

Are you currently on a weight loss program? *

Yes
No

If you answered yes to the question above, which program are you presently on?

Please fill in the name of the program below.

What type of consultation would you prefer? *

Please select one choice.

Face to face at our office.
Telephone consultation with a provider.
Not interested in a consultation at this time.

If you would like, you may upload a digital photograph for your consultation.