Weight Loss Breakthrough Application
Please answer all questions fully to be considered for the program.
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Email *
What is your name? *
Phone number *
Tell me a little bit about your weight situation. *
When it comes to losing weight what are your biggest challenges? *
On a scale of 1-10 (10 being highest), how important is it to you to lose weight...and why? *
What is the #1 obstacle that's kept you from solving your weight challenges? *
What is your current height and weight? *
Where would you like your weight to be in 6 months? 12 Months? *
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