Weight Loss Pre-Qualification

Complete the following form to see if you qualify. Results instantly e-mailed to you.

How much weight would you like to lose in the next 6 months? *

Under 20 lbs

20-30 lbs

30-40 lbs

40-50 lbs

50+ lbs

What is your current weight? *

Have you tried to lose weight in the past? *

Yes, I have tried several times

Yes, I have tried a once or twice

No, I have never tried

Do you struggle with carbohydrate cravings?

Yes

No

Do you feel hungry most of the time?

Yes

No

Do you have a personal or family history of thyroid cancer?

Yes

No

Do you have a history of pancreatitis?

Yes

No

Our most popular program starts at $69 per week for 6 months. Would you pay this upfront or prefer a payment plan? *

I can pay it upfront

I would need a payment plan

What is your credit score? (To see if you can be approved for our payment plans) *

Under 400

400 to 500

500 to 600

600 to 700

Above 700

Where should we send your results?

First Name *

Last Name

Phone *

Email *

I agree to the terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business. We will never SPAM.

NEXT