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Demographics
First Name
Last Name
Email Address
Phone Number
Mailing Address
Country
- None -
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United States
Street address
Street address line 2
Street address line 3
City
State
- Select -
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Armed Forces (AE)
Armed Forces (AP)
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Texas
Utah
Vermont
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Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code
Gender
Male
Female
Date of Birth
Date
Occupation
Marital Status
- None -
Single
Married
Divorced
Widowed
Number of Children
children
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone
Motivation
What is your motivation for losing weight?
Please list any weight loss programs you have tried in the past.
Order
Please list any weight loss programs you have tried in the past. (value 1)
Weight for row 1
0
If qualified for this weight loss program, what date would you plan on starting?
Date
Diet
Daily Activity Level
Sedentary
Lightly Active
Moderately Active
Very Active
Current Weight (lbs)
Desired Weight (lbs)
Height (inches)
Medical
Are you currently pregnant, breast feeding, have active cancer or active gall bladder disease (cholecycstitis)?
Yes
No
If yes, you are not eligible to participate in this program.
Select all that apply.
Pregnant
Breast Feeding
Active Cancer
Active Gall Bladder Disease (Cholecystitis)
History of Eating Disorder (Diagnosed)
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
PICA
Rumination Disorder
Avoidant or Restrictive Food Intake Disorder
Purging Disorder
Night Eating Syndrome
Surgery
History of Bariatric Surgery
Gastric Bypass (Roux-en-Y-Gastric Bypass)
Lap Band (Laparoscopic Adjustable Gastric Banding)
Sleeve Gastrectomy
Biliopancratic Diversion with Duodenal Switch
How much weight have you lost with surgery?
lbs
How much weight, if any, did you put back on?
lbs
Have you had your gall bladder removed?
Yes
No
Diabetes
Have you been diagnosed with diabetes?
No
Type I
Type II
Other
Year Diagnosed
Diabetes Medications
Order
Diabetes Medications (value 1)
Weight for row 1
0
Blood Pressure
Have you been diagnosed with high blood pressure?
Yes
No
Year Diagnosed
Blood Pressure Medications
Order
Blood Pressure Medications (value 1)
Weight for row 1
0
Thyroid Condition
Have you been diagnosed with a thyroid condition?
Yes
No
Year Diagnosed
Thyroid Medications
Order
Thyroid Medications (value 1)
Weight for row 1
0
Cholesterol
Have you been diagnosed with high cholesterol?
Yes
No
Year Diagnosed
Cholesterol Medications
Order
Cholesterol Medications (value 1)
Weight for row 1
0
Do you experience any of the following even if they are minor and go away on their own?
High Blood Pressure
Heart Disease
Fibromyalgia
Hip / Knee Pain
Neck Pain
Digestive Problems
Numbness
Osteoporosis
Headaches
Upper / Low Back Pain
Arthritis
Stress / Irritability
Chronic Inflammation
Hypoglycemia
Thyroid Problems
Chronic Fatigue
Sinus / Allergy
Do you experience any other problems, even if they are minor?
Order
Do you experience any other problems, even if they are minor? (value 1)
Weight for row 1
0
Are you currently on any other medications and if yes, for what?
Order
Are you currently on any other medications and if yes, for what? (value 1)
Weight for row 1
0
Do you have any other health challenge you feel is important for us to know about?
Would you say you are an "Emotional Eater?"
Yes
No
What foods do you crave?
Order
What foods do you crave? (value 1)
Weight for row 1
0
My two greatest stressors are
Order
My two greatest stressors are (value 1)
Weight for row 1
-1
0
1
My two greatest stressors are (value 2)
Weight for row 2
-1
0
1
Significant Emotional Trauma
Age
Order
Age (value 1)
Weight for row 1
0
Emotional Trauma
Order
Emotional Trauma (value 1)
Weight for row 1
0
Informed Consent and Release of Liability
Informed Consent and Release of Liability
I understand that my use and consumption of any ChiroThin product or engaging in any weight loss program including the type that is to be used in conjunction with ChiroThin, have inherent risks to my health and well-being, including but not limited to headaches, nausea, dizziness, vomiting, fatigue, pain, loss of consciousness, shortness of breath and other ailments. I understand as well that rapid weight loss of over 1-2 lbs. per week is considered by most in the weight loss medical community to be excessive and may lead to ailments similar and in addition to those mentioned above. Therefore, I understand that my failure to follow the weight loss program exactly as described to me by my physician or chiropractor can result in severe temporary and/or permanent medical conditions in addition to those mentioned above. I understand that I am not use or consume any of the ChiroThin products if I am pregnant or think I might be pregnant. I understand that, as a dietary supplement, ChiroThin has not been approved by the FDA or any Federal or State authority. I additionally understand that the ChiroThin Weight Loss Program is not meant to diagnose, treat or cure any disease or medical condition and that I am to undergo participation in the ChiroThin Weight Loss Program only under doctor supervision. I also understand that I should consult with my doctor prior to starting ANY exercise or nutritional supplement program. I understand that, if I experience any ailment, including but not limited to headaches, nausea, dizziness, vomiting, fatigue, pain, loss of consciousness, shortness of breath and other ailments, I should immediately stop using or consuming the ChiroThin product and, if my symptoms do not resolve immediately, I should consult my physician or go to the hospital emergency room. I hereby consent to, and assume the risks associated with, the use and consumption of ChiroThin product and agree to follow the recommendations and instructions of my physician. I further agree not to use or consume any ChiroThin product without the advice, counsel, and recommendations of my physician. I understand that Neuroemotional Technique (NET) is one of the techniques that may be used during my care. NET does not make claims as to what may have happened in the past. All memory events are considered “emotional reality” because events may or may not correspond with actual or historical reality. I hereby release, discharge and agree to indemnify my physician(s) at ChiroThinTracker, NET, ChiroNutraceutical, their agents, servants employees and affiliates from any and all liability, claims, causes of action and demands for personal or bodily injury or death that I or my personal representatives might have or might hereafter acquire through my use or consumption of ChiroThin products.
Program Agreement
ChiroThinTracker Program Agreement I understand due to the nature of this weight loss program, although it is doctor supervised, it is up to me to follow the instructions as outlined in the training videos on http://sextonchiropractic.chirothintracker.com/ application and in my program booklets, handouts and doctor modifications as communicated to me through the http://sextonchiropractic.chirothintracker.com/ app. I understand that no results are guaranteed and that results vary from patient to patient. I understand that I may contact my doctor(s) with my questions and that they are available through the patient portal and email or video conference for supervision and support, but they are not ultimately responsible for my actual weight or inch loss. I understand that I must follow the instructions outlined in the instruction manual, on the instructional videos and as modified by my doctor(s) and/or their team for optimal results. I understand that straying from the program in any way will negatively affect my weight loss results. I understand that there are no refunds for opened products, missed or unused appointments that are built into the programs. I agree to not sell, gift or share my product formula with another individual. I agree that if I spill or lose my product formula within the first 4 weeks of my program I may purchase one accidental replacement bottle of drops for $500. Finance and Payment Agreement I hereby authorize ChiroThinTracker to charge my credit card for the Amount Due at Signing for the products and/or programs I have selected from the online store and said amount is to be charged on the date this agreement is signed. If a financed option was chosen, I further authorize ChiroThinTracker to charge my credit card for monthly payment amounts, as outlined in the program financing options until the balance is zero. I understand and agree to the payment schedule described herein and further, I understand that the monthly amount described in the finance options will be processed automatically by our merchant processor.
Media Release
For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to the photographing of myself and/or the recording of my voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. I understand that the term “photograph” as used herein encompasses both still photographs and motion picture footage. I further consent to the reproduction and/or authorization by ChiroThin and ChiroNutraceutical to reproduce and use said photographs and recordings of my voice, for use in all domestic and foreign markets. Further, I understand that others, with or without the consent of ChiroThin and ChiroNutraceutical, may use and/or reproduce such photographs and recordings. I hereby release my ChiroThin supervising chiropractor, ChiroThin, ChiroNutraceutical, and any of its associated or affiliated companies, their directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind on account of such use.
I Agree
By checking this box, I agree to the Informed Consent and Release of Liability.
To sign your consent to the agreement above, type your full, legal name in the box below.
I do not consent to the media release.