Take It Off Keep It Off Application Form

WEIGHT LOSS FOR LIFE

All information shall remain confidential.

First Name*
Surname*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Skype ID
Gender*
- Male
- Female
Age
Height*
Current weight*
Desired weight*
When were you last at this weight?*
What diets have you tried in the past?*
Are you on any kind of weight loss program right now?*
Please list your main health concerns*
Other concerns
The most important thing I should do to improve my heath is:*
What results would you like to acheive with your health over the next 12 months?*
Describe how motivated you are to improve your health and your life*
On a scale of 1 to 10 (With 10 being YES! I'm ready to go) how ready are you to invest in your health and yourself?*
Anything else you would like to share to suppoert your application?
I understand that:*
- Neil works with an extremely limited number of clients, it’s not possible to accept everyone who applies for the program, and there is often a waiting list.
I understand that:*
- The information provided in this program is for general educational purposes, and is not intended to take the place of advice from my medical professional, licensed dietician or nutritionist.
I understand that:*
- II am solely responsible for my health care and activity choices. and should work simultaneously with a trusted health care professional.
Phone
This field is for validation purposes and should be left unchanged.