Stimulock Health Consultation Form
Welcome to the Stimulock System! We look forward to working with you in reaching your weight loss goals. Please provide the information below so we can better serve you. All information is kept confidential. Thank you.
Email *
Full Name *
Gender *
Birthdate *
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Phone
Shipping Address *
Who referred you?
Do you have a Stimulock Practitioner you'd like to work with?
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Height
Current Weight
Goal Weight
Occupation
Average Daily Activity Level
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Are you pregnant or nursing? *
Please list any current prescribed medications *
Please list any vitamins and/or supplements you currently take *
Please list any known food allergies *
Please share any current health concerns
What previous diet programs have you tried in the past 5 years? 
How would you describe your diet history?
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MONEY BACK GUARANTEE: If you do not lose significant weight during the first 10 days of following the Stimulock System, just return the bottle and your complete food journal to receive a refund minus any shipping charges. If at any time you experience delays in weight loss, gain weight, or have any questions or concerns, please contact your Stimulock practitioner. We want to help you get your health and confidence back, feel better, and lose the weight you want to lose. *
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