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Name *

First Name

Last Name

Phone *

Country

(###)

###

####

What is your date of birth? *

MM

DD

YYYY

Where does your current body weight land approximately? *

Under 100 lbs

100-150lbs

150-200lbs

200-250lbs

250-300lbs

300-350lbs

350-400lbs

400-450lbs

450-500lbs

500-550lbs

In the past when you've dieted... *

Check all that apply

I lose weight really quickly

It's always been difficult to see the scale budge

I lose weight at a pretty even pace

It comes off much slower than it used to

What used to work doesn't work anymore

I lose a little then it plateaus

Nothing I've tried gets the scale to move

I always keep the weight off that I lose