Eligibility Form
Let's check your eligibility.
Email
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Let's enter your date of birth
Select a month
January
February
March
April
May
June
July
August
September
October
November
December
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First Name
Last Name
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Phone/Mobile
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Gender
Male
Female
Age
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What is your weight and height?
Weight (pounds)
Weight (Kg)
Height (feets)
Height (meters)
Body Mass Index
Body Fat Percentage
Body Fat Percentage
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State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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What are your top goal for losing weight?
Lose weight and maintain a healthier BMI
Improve overall health and reduce risk of chronic diseases
Increase energy levels and improve physical activity
Better manage existing medical conditions (e.g., diabetes, hypertension)
Prevent future weight gain and establish long-term health goals
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Have you or anyone in your family been diagnosed with medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2?
Yes
No
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Are you currently pregnant, planning to become pregnant, or breastfeeding?
Yes
No
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