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Last name
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Email
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How did you hear about us?
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What is your primary goal with this program?
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Please be as specific as possible e.g. if weight loss is your primary goal, how much weight & in what time frame?
Do you have any health concerns?
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When do you want to get started?
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Is there anything coming up that may impact your commitment to this program?
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If we need to contact you by phone, what is the best number to reach you on?
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Pricing
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$79.99 - Monthly
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