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GLP-1 Weight Loss program
WELCOME! We are so excited to help you on your weight loss journey! We will contact you to follow up on the form.
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Name *
Date of Birth *
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DD
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Address *
Phone Number *
Current Weight *
How much weight would you like to loose? *
Do you or anyone in your immediate family have a history of thyroid cancer? *
Do you have a history of any of the following? *
What are your health/weight loss goals? *
What is your availability for a in person/in home initial consult? (This 60-90 minute physical exam includes bloodwork). List general times (i.e. mornings on Mondays) *
Are you ready to setup at $300 non-refundable home visit to take control of your weight and your health? *
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