Eligibility Form – The Confidence Clinic

Which state do you live in?(Required)

Arizona

California

Colorado

Missouri

New Mexico

New York

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Are you here to get evaluated for weight loss?(Required)

Yes

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What is your gender at birth?(Required)

This will help us understand your body complexity so we can assess you better.

Female

Male

Other

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Ok, let's talk about numbers. How tall are you?

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How much do you weigh?(Required)

This helps us calculate your BMI. BMI is one factor that we use to determine your weight care path, so it's important to be as accurate as possible.

Please enter a number from 0 to 700.

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What goals are you looking to accomplish?(Required)

Choose all options that apply

Lose weight

Improve general health

Look better

Improve confidence

Improve energy

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Just few more questions

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What have you tried in the past?(Required)

Choose all options that apply

Exercise

Dieting

Weight loss supplements

Intermittent fasting

Medical weight loss program

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What is your date of birth?(Required)

Our bodies and needs change with age (think hormones), so we'll need to know when you were born.

Month

Day

Year

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What is your email?(Required)

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What is your phone number?(Required)

Please enter a valid ten-digit phone number. The number cannot start with zero or one.

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Can we also send you text messages about your prescription including tracking information and refill information?(Required)

Yes

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You're getting closer to your weight loss goals

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Name(Required)

First Last

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Shipping Address(Required)

Where would you like us to ship your medication?

Street Address Address Line 2 City State ZIP Code

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