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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( X )
INITIAL VISIT
$
99.00
Quantity
1
2
3
4
5
6
7
8
9
10
Follow up Visit
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: