Patient Consultation Questionnaire

Health Care Analysis

Step 1 of 3

33%
  • MM slash DD slash YYYY
  • Pounds (LBS)
    Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Name of the clinic or company that is offering weight loss services

  • Questionnaire

    Please answer the following questions honestly, so we can do our best to help you reach your goals.
  • Please enter a number greater than or equal to 0.
  • In weeks
    Please enter a number greater than or equal to 0.
  • In weeks
    Please enter a number greater than or equal to 0.
  • Please check all that apply
  • Please check all that apply
  • Please check all that apply
  • Please provide any additional information that will help us determine what weight loss program is right for you.

Contact Us

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Financing Options Available

Flexible payment plans specials include:

  • $99 for the first 6 months- Requires only $99 to start.
  • 90 Day Deferral – Payments of only $0 for the first three months.

The following is a breakdown of estimated rates, and their associated monthly payment, for the H2 Body Slim Elite base unit ($20,550). Rates quoted are subject to change. Actual monthly payment will be determined after complete review of your credit history.

Term Monthly Payment
12 Months $(1,778.12)
24 Months $(920.08)
36 Months $(634.52)
48 Months $(492.10)
60 Months $(406.91)