Intake form

Help us serve you better

Name *

Email address *

What is your primary goal with weight loss?

Please select at least one option.

General health improvement

Increased energy levels

Improved self-esteem

Medical reasons

Have you previously tried any weight loss medications?

If yes, please specify which medications you have tried.

What is your current weight?

What is your target weight?

Do you have any existing medical conditions?

Please select at least one option.

Diabetes

Hypertension

Heart disease

Thyroid issues

None

Are you currently taking any medications?

How did you hear about chloe business?

What is your preferred method of consultation?

Additional questions or comments

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Weight loss