First Name
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Last Name
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Email
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Phone
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Instagram Handle
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Please briefly describe your weight loss goals and desired outcomes
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On a scale of 1-10, how committed are you to achieving your weight loss goals?
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1
2
3
4
5
6
7
8
9
10
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Are you willing to invest the time, effort and resources required to achieve your weight loss goals?
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Yes
No
Is there anything else you would like us to know about you and your weight loss goals?
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