Note: A client may be advised to seek medical advice prior to initiating and/or during weight loss, based on his or her health profile.
Last Name (required)
Invalid Input
First Name (required)
Invalid Input
Phone (required)
Invalid Input
Best time to reach you by phone. Please give a 2 hour time period between 9-6 Central Time. (required)
Invalid Input
Email (required)
Invalid Input
Whom may we thank for referring you?
Invalid Input
Allergy Information
Do you have any food allergies? (required)
Invalid Input
If so, please list
Invalid Input
Do you have any medication allergies? (required)
Invalid Input
If so, please list
Invalid Input
Do you have any of the following conditions?
(Please check all that apply)
Invalid Input
Invalid Input
If so, has your primary medical care provider consented to your participation in this weight loss protocol?
Invalid Input
If your answer is “NO” to the above question, you will not be accepted to participate in our protocol.
You must take vitamins and minerals while you are on Sustain. If you stop taking them, you may experience undesirable side effects.
Please Intial (required)
Invalid Input
(If you have health problems not indicated on this health profile, please consult your physician before beginning this program)
Online Disclaimer
Please check that you have read, understand, and agree with each of the following statements
(required)
Invalid Input
(required)
Invalid Input
(required)
Invalid Input
(required)
Invalid Input
Terms and Conditions
Terms and Conditions Verification (required)
Invalid Input
The signatory client hereby recognizes the veracity of the information provided herein and that he/she has made an informed decision to go on the Sustain Weight Loss Solution.
Name (required)
Invalid Input
Date (required)
Invalid Input
Submission of this form constitutes all information provided is accurate and valid.
