Registration If you are interested in our Comunity Weight Loss Challenge and would like to participate it please fill in the form below. We will contact you
Name
Phone Number *
Email *
Date of Birth *
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Where did you see our Advertisement :
Are you serious about wanting to lose weight? *
Yes No Not Sure
How Many Kilograms would you like to lose ? 1-5 6-10 11-20 more 1 Pound = 0.45 KG
Which of the following methods have you tried before to lose weight? *
---Select a choice--- Exercise Medication Eat Less Operation Liposuction Change of Diet More than one from the list Other None
What is/are the reason(s) why you would like to lose weight?: *
Weight *
(Kilograms)
Height *
(cm)
