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Paragon Health & Wellness

Weight Loss Sign Up

Paragon Health & Wellness

Weight Loss Sign Up

Weight Loss Sign Up

Contact Us

Name *

First Name

Last Name

Email *

Message *

Number

Thank you!

Name *

First Name

Last Name

Email *

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DOB

MM

DD

YYYY

Height & Weight *

Goal Weight *

Do you have or have a history of the following? *

None

Diabetes

Thyroid Cancer or Masses

MEN Pancreatic Cancer

Pancreatitis

Pregnancy/Breast Feeding

Delayed Gastric Emptying

Weight Loss Surgery

Heart Attack

Stroke

None

Are you willing to commit to regular follow-ups and a structured weight loss program? *

Are you currently taking any medications? (Include space to list medications, doses, and frequency *

Phone

(###)

###

####

Do you understand the importance of uploading lab results to start the program? *

Yes

No

Have you read and agreed to the terms and conditions of treatment? (in FAQ) *

Yes

No

Checkbox *

Yes

No

Do you consent to be contacted via phone, email, or text regarding your program? *

Yes

No

Do you understand that Paragon Health does not accept insurance for this program? *

Yes

No

Thank you!

Paragon Health

paragonhealthal@gmail.com