Busy Bariatrics Application

I am so excited you have decided to book a call with us! It is crucial you fill out this form so we can best serve you on the call.

First Name

Last Name

Phone *

Email *

Do you agree to push through your fears, show up for yourself, and commit to the opportunity you have in front of you?

Yes

No

On a scale of 1-5 how ready are you to make this goal a reality? 1 being you aren't and 5 being I want to start tomorrow!

What has been your biggest challenge to facing your goals?

Describe your perfect outcome? What would you have to accomplish with your body, health, and fitness to say you've "accomplished" your biggest goal after bariatric surgery?

What have you already tried to reach this goal?

Do you feel you are able to make a decision on joining the program on your own?

Yes

No

Will you need a significant other involved in your decision making? (totally cool if so we can set up a joint call!)

Yes

No

What type of weight loss surgery have you had?

I am considering weight loss surgery

Gastric banding (Lab Band)

RNY

Gastric Bypass

I am not considering weight loss surgery

What is one thing you would like me to know about you prior to our meeting?

I agree to terms and conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.