New Client Weight Loss Assessment
Please complete this quick assessment before starting your weight-loss journey. This helps us create a personalized plan tailored to your goals and support your results every step of the way.
Name
*
First Name
Last Name
Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Weight
*
Goal Weight
Height
*
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Goals & Lifestyle
Main Goal
Lose weight
Tone Body
Boost Metabolism
Other
Target Areas
Stomach
Arms
Thighs
Overall
other
Start Date
Immediately
Within 2 weeks
Just exploring
Other
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Medical & Health Information
Medical Conditions
*
Current Medications
*
Do you have any allergies?
*
Previous Peptides/injection?
*
Yes
No
Pregnant or Breastfeeding?
*
Yes
No
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Commitment
Able To Commit To Weekly Visits
Yes
No
Interested in
Pay per visit
Monthly membership
Not sure as yet
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Booking Availability
What days works best for you?
Weekdays
Weekends
Flexible
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Agreement/Consent
Check box
*
I understand this is a weight-loss support program and results may vary. I agree to follow guidance provided and understand consistency is required.
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Additional Comments
Appointment/Payment
*
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INITIAL VISIT
$99.00
$
99.00
Quantity
1
2
3
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9
10
Follow up Visit
$50.00
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Submit
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