Private Consultation Form
Fill out the full form below. We will find your true Obstacles to Weight Loss!
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When did you
Do You have
or body hair?
Is your cycle
(3-5 days with last days being light?)
Have you had any
Do You take Birth control pills/ injections?
Type Of Birth Control?
Do you work regular hours between 8-6pm?
Have you ever seen an endocrinologist or doctor for glandular problems such as thyroid?
If yes, what were the results?
Please list any medications :
Tell me about any Health Issues :
Digestive problems, bowel irregularity, energy or sleep problems
HOW MUCH WEIGHT (INCHES) WOULD YOU LIKE TO LOSE