Weight Loss Intake Form

(After you complete this quick intake form you can schedule your appointment.)

First Name *

Last Name *

Cell Phone *

Email *

State *

City *

Occupation *

Age *

By checking this box you indicate that you DO NOT have any of the conditions below. Unfortunately we are not able to accept any clients with the following health conditions listed below into the weight loss program. Please do not reserve a time if any of these apply to you:

Diagnosed with PCOS
Active Cancer Treatment Patient
Pregnant or Breast Feeding
Diagnosed history of anorexia, bulimia, or binge eating.

How many pounds would you like to lose? *

< 20

20-30

31-40

41-50

51-60

60+

How soon are you wanting to start losing weight? *

Immediately - Tomorrow

3-7 days

1-2 weeks

2-4 weeks

Month +

What are the top 2 reasons you want to lose weight? *

Health (current conditions)

Health (future conditions)

Self-Confidence

Family (Be around for kids / grandkids)

Improve Energy

Appearance

Upcoming Event (Wedding, trip)

Improve Fitness

Other

What best describes how you feel about reaching your goal? *

Goal

I will do whatever it takes. I am sick of where I'm at and will not tolerate it any more.
I am a little intimidated, yet with a proven system and support, I'm sure I can reach my goals.
I'm really just looking for a quick fix without having to change a whole lot in my life.
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You are more than welcome to bring someone with you to your consultation as well.

Appointments / General

Fax

651-342-2720

Email

[email protected]

Office Hours

Monday - Thursday

8:30am - 12:30am

2:00pm - 5:30pm

Friday

8:30am - 12:30pm

Address

1290 West Frontage Rd

Stillwater, MN 55082

HIPPA COMPLIANCE

PRIVACY POLICY AND TERMS OF SERVICE

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