Busy Bariatrics Application

I'm so excited for the opportunity to work with you inside Busy Bariatrics! It is crucial you fill out this form so we can best serve

you on the call.

-Coach Kylie

First Name

Last Name

Phone *

Email *

Instagram Username

How did you hear about Busy Bariatrics?

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

Yes

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?

How much do you have budgeted for monthly coaching services?

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

Yes

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

Yes

What type of weight loss surgery have you had?

I am considering weight loss surgery

Gastric banding (Lab Band)

RNY (Gastric Bypass)

Vertical Sleeve Gastrectomy (VSG)

I am not considering weight loss surgery

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

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.