Fill Assessment Form

Please note that all fields need to be filled out completely (including meals), or you will be asked to resubmit the form. In addition you must have completed both the Kickstart and Fillosophy online sessions before you can submit this form.

Profile information

35 Prince Arthur Ave. (Toronto)
Calgary
Richmond, BC
Kitchener
Bowmanville
Edmonton
Sudbury
Hamilton
Richmond Hill
Mississauga
Montreal
Ottawa
Halifax
Fort McMurray
Remote Doctor/Nurse


Please answer the following questions.

Describe what you typically eat for...





Do you feel hungry in between meals?
Yes No Sometimes

Do you take small bites and chew each bite well?
Yes No Sometimes

Do you avoid drinking fluids with your meals?
Yes No Sometimes

Do you eat a full serving of protein with every meal?
Yes No Sometimes

Have you experienced any vomiting, acid reflux, or other discomfort since your last adjustment?
Yes No Sometimes





Please indicate any other Slimband programs you're interested in

I would like to learn more about Slimband's Botox® or Juvederm® program.

I would like to learn more about Slimband's plastic surgery program.

I would like to recommend a friend or family member to Slimband.*

* As a Slimband patient you are eligible for a cash referral bonus.

Confirmation
Have a question?
Please contact the
Slimband Clinic

1.800.298.0684
support@slimband.com

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