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(561) 680-3440

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Name *

Phone *

Email *

City / Town *

How Many Pounds Would You Like To Lose? *

How did you hear about us? *

Radio: 103.1 WIRK - Tim Leary

Radio: 97.9 WRMF/KVJ Show - Tracy St. George

Radio: 850 WFTL - Jennifer Ross

Radio: 88.1 - Way FM

Radio: True Oldies - Brian Craig

Radio: 1290 WJNO News - Joel Malkin

Radio: Sunny 107.9

Radio: 640AM - Sports Radio - Stephen Diener

Radio: 100.3 - Legends Radio - Mike

Radio: 92.1 - WZZR - The Greek

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Google

Referral / Other: How did you find out about us or who told you about us?Referral / Other: How did you find out about us or who told you about us?

How old are you? *

18-24

25-34

35-44

45-54

55-64

65+

Tell us a little about yourself! *

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Disclaimer: Individual weight loss results will vary. Typical weight loss is 1-4 pounds per week based on the clients age, weight and weight loss goals. Calorie restriction is required to lose weight and many of our clients who complete the program will lose between 10-20% of their total body weight in 60 days.

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