Let's get started! Provide us with some information about you.

(Because this is a real prescription, we need to know whose name to put on the bottle)

Full Name

Phone *

Email *

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

Which weight loss goal is most important to you?

lose inches

lose 10 - 20 pounds

lose 25 - 50 pounds

lose 50+ pounds

Any additional goals that you need help with?

Are you currently a member of a weight loss support group or program?

Yes

No

What strategies do you use to stay motivated on your weight loss journey?

workout

positive thinking

not applicable to me at this time

Do you track food intake?

Yes

No

What is the biggest challenge you face when trying to lose weight?

getting started

staying committed

plateau

time management

I don't have any challenges

Do you track your exercise regularly?

Yes

No

Describe your current level of physical activity.

sedentary

lightly active

moderately active

very active

Do you experience any problems suppressing your appetite? *

Yes

No

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