Full Name
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Email
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Phone
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How Many Days Per Week Are You Physically Active/Exercising?
0 Days
1 Day
2 Days
3 Days
4 Days
5+ Days
Are You On Any Of The Following Diets?
Keto
Vegetarian
Paleo
Vegan
Other/None
What Are Your Weight Loss Goals?
Lose stubborn weight
Fit into smaller clothes
Boost self-confidence
Feel comfortable
Other
Any Questions About This Treatment?
What will my results look like?
How long will it take to see results?
What's the cost?
Is there financing available?
How many injections will I need?
Other
Are you willing to give this program 6 months to achieve results?
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