Consultation Questionnaire - Healthy Habits Weight Loss Business Builders

Patient Consultation Questionnaire

Name*
First Last
Email*
Enter Email Confirm Email
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Weight*
Please enter a number greater than or equal to 0.
Pounds (LBS)
Height*
Please enter a number greater than or equal to 0.
Feet
Who encouraged you to lose weight?
How important is it to you to lose weight?*
What important reason, special occasion, or goal date do you have to lose weight?
How many pounds would you like to lose?*
Please enter a number greater than or equal to 0.
How fast do you want lose the weight?*
Please enter a number greater than or equal to 0.
In weeks
Would you commit to one visit a week?*
- Yes
- No
Have you ever attended any other weight reduction centers? If so, which ones?
What kinds of diets have you tried on your own?
What is the longest you have been able to stick with a diet?
Please enter a number greater than or equal to 0.
In weeks
Does your family support your weight loss efforts?*
- Yes
- No
Do you eat because of emotions?*
- Yes
- No

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)