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*Serious Inquiries Only*

Consult Request Form

First Name *

Last Name *

Phone *

Email *

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What is your current age? *

How long has weight been an issue for you? *

Are there any additional symptoms or concerns you have? Please be specific. *

How are your symptoms or weight problem affecting your day-to-day life? Please provide as much detail as possible. This allows us to be specific in your weight loss recommendations. (Our mission is to provide as much value as possible). *

What have you tried in the past to lose weight and relieve unwanted symptoms? Please share why you believe these did not work for you. Include any specific diets, detoxes, workout programs, medications, supplements, etc *

What do you believe is your ideal, healthy weight? *

How much weight do you desire to lose? *

Less than 20 lbs

20-50 lbs

More than 50 lbs

Are you a Type 1 Diabetic (insulin dependent)? *

Yes

No

Our program is one of the best choices available for Type 2 Diabetes, but unfortunately it is not ideal for Type 1 Diabetes. If you are Type 1 Diabetic, we would not be able to accept you into our program and we wish you all the best.

Are you absolutely sure you are a Type 1 Diabetic? *

Yes

Not Sure

Type 1 Diabteic = Autoimmune Insulin Dependent (typically from childhood); Type 2 Diabetic = Adult Onset (most common)

Are you a Vegan or Vegetarian? *

Yes

No

Unfortunately, our program has not been shown to funtion optimally for vegan or vegetarian eating regimens. We wish you all the best in your weight loss journey.

Assume you're 100% confident that our custom approach will help you reset your metabolism, lose stubborn weight, & relieve unwanted symptoms. How would you describe your ability to purchase treatment? (Please note: Our treatments are not covered by insurance. We accept HSA. Assume you KNOW this will work for you!) *

Yes, I have cash or credit to invest in my health.

No, unfortunately, I am broke, maxed out.

We understand finances can be a concern. There are ways to qualify for financing (requires a credit check). Are you still interested in making your health a priority? *

Yes

No

Last Question: We offer a 100% No-Cost Weight Loss Appointment. If you qualify for a call, do you agree to show up on time for your appointment? *

Yes. Absolutely! I will double check my calendar and commit 100%.

Maybe. I'm not so sure I am serious about this.

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