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R3VOLVELIFE Weight Loss Application

We want to learn the best way to serve you. Would you benefit from our weight loss program? Or are you looking for exclusive, challenging classes to take your fitness to the next level? Fill out our brief application and we will follow up with a FREE Fitness & Lifestyle Assessment. 

Click the button below to start.

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Question 1 of 11

Which one is holding you back the most from achieving your personal goal(s)?

A

A Negative Mindset (I.e Fall victim to your excuses etc...)

B

Lack of Exercise Routine

C

Unhealthy Diet

Question 2 of 11

How much weight do you want to lose?

A

5 to 15lbs

B

15 to 25lbs

C

25 to 35lbs

D

35lbs and more

Question 3 of 11

How does it make you feel at your current weight?

Question 4 of 11

When was the last time you felt great (i.e. Before having children, get married etc…)?

Question 5 of 11

What other program(s) (i.e. Gym Membership, Personal Trainer, Weight Watchers etc…) have you done in the past?

Question 6 of 11

What do you think is holding you back?

Question 7 of 11

What does your dream body and healthy lifestyle look like?

 

Please describe:

Question 8 of 11

How is your current health and/or lack of a healthy lifestyle affecting your relationships (i.e. Spouse, kids, social etc…)?

Question 9 of 11

How important is it for you on a scale of 1 - 10 to make the changes needed?

 

Select one:

A

1 (Not important)

B

2 to 4 (Some what important)

C

5 to 6 (Important)

D

7 to 9 (Very Important)

E

10 (Extremely Important)

Question 10 of 11

On average, how much have you invested monthly to achieve your weight loss goals in the past?

A

Under $50

B

Between $50 - $100

C

$100 and Up

Question 11 of 11

Please provide your:

First Name

Contact Number

Best Time To Contact You

(We will contact you within the next 24hrs to 48hrs):

Confirm and Submit