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Congratulations on taking the next step to weight-loss and improved health that you can feel and see in a very short time.

If you're really ready to lose weight for the last time, consider this your invitation to a better lifestyle. Please answer the following questions, so that we can better assist you with your weight loss needs. All information you provide is strictly confidential.

* First Name:
* Last Name:
* Email Address:
* Day Phone:
* Evening Phone:
Address:
Line 1:
Line 2:
City:
St./Prov.:
 Zip: 
Country:
Any Comments?:
How serious are you about losing weight?:
How much weight would you like to lose?:
What weight-loss programs have you tried?:
Best time to reach you!:
What is your current weight?:
What is your goal weight?:
What is your Height?:
What is your Age?:
Do you have any health concerns?:
What is the reason you want to lose weight?:
How many times a week do you eat out?:
 
Tish and Associates
525 W. Arapaho Rd. #15 
Richardson, TX. 75080
 		 888-766-6101
972-231-2636