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Omaha & Lincoln Hypnosis
Weight Loss Intake Form

Your Success is our #1 priority.
Your success begins by filling out this questionnaire as completely as possible.

Please fill out all the information

Do you feel out of control?

Are you embarrassed about your weight?

Did you know hypnosis is 100% safe?

Does your family support your weight loss efforts?

Has being overweight caused you pain and suffering?

If you have pressed the “Submit” button and nothing happened please scroll up the screen and find the Red Box of Required information.