Services
Testosterone Replacement Therapy
Weight Loss
Weight Loss Injections
Extra Services
Vitamin Injections
Erectile Dysfunction (ED)/ Sexual Wellness
HGH Peptide Therapy
Supplements
Physicals
Locations
Katy, TX
Spring, TX
Pearland, TX
Bridgeland, TX
Coming Soon
About Us
FAQ
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Services
Testosterone Replacement Therapy
Weight Loss
Weight Loss Injections
Extra Services
Vitamin Injections
Erectile Dysfunction (ED)/ Sexual Wellness
HGH Peptide Therapy
Supplements
Physicals
Locations
Katy, TX
Spring, TX
Pearland, TX
Bridgeland, TX
Coming Soon
About Us
FAQ
Appointment
Weight Loss Support Survey
Fill out our questionnaire
Name
(Required)
First
Last
Age
(Required)
Phone Number
(Required)
Email
(Required)
Current weight
(Required)
Desired weight
(Required)
Have you tried prescription weight loss medications in the past
(Required)
Yes
No
list the medication have you taken already
how much dose have take ? type the names here..
Date they last took it
MM slash DD slash YYYY
Time spent on medication
Hours
:
Minutes
AM
PM
AM/PM
Have you attempted any special diet routines?
(Required)
Yes
No
Did you lose weight from this diet?
(Required)
yes
no
How much weight did you lose from this diet?
(Required)
1-5kg
5-10kg
more than 10kg
Elaborate Your weight loss diet list…
(Required)
How much period have you taken the diet plan(in days)?
(Required)
Do you have any dietary restrictions?
(Required)
Yes
No
List your dietary restrictions…
(Required)
Do you have any other medical conditions?
(Required)
Yes
No
Elaborate your medical restrictions….
(Required)
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