Application
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Your information will be kept strictly confidential.
Email *
Please confirm your email address. *
Name (first and last) *
What is your phone number? *
Age *
Approximate current weight *
Height *
Why do you want to adopt a Ketogenic Lifestyle? Check all that apply. *
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Describe your struggle with weight. Check all that apply. *
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Do you have (or have you ever had/been treated for) disordered eating? *
Do you have any medically diagnosed, pre-existing health conditions that contraindicate a Ketogenic Lifestyle? (ie. people kidney damage, heart disease, pregnant or nursing, type 1 diabetes, liver or pancreatic condition, gallbladder removal) *
If you have a promo code, please enter it here. If not, please type N/A. *
A copy of your responses will be emailed to the address you provided.
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