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Register for Dr Gily's Weight Loss Program

IMPORTANT: Please note this section of our site is currently being updated. Some parts of it may not be functional.

Fields marked by * are required!
First Name*
Last Name*
Email address*  (where activation code will be sent)
Email preference*
Desired username*  choose a different username than those appearing below while you type
taken usernames
Desired password*
Reason for weight loss:  (max. 255 characters)
Age*  years
Gender*  Female  Male
Current Weight*
 kgs.     OR  lbs.
Current Height*
 meters     OR  feet    inches
Are you pregnant?  Yes  No
Past medical history*
(check all that apply)  

 Diabetes  High Blood Pressure  High Cholesterol
 Anorexia  Heart Disease  Arthritis
 Unstable Psychiatric Condition  Unstable Medical Condition
Other health problems:
 Sedentary  Light  Moderate  Intense
How did you find us?*
Terms and Conditions*  I have read and I agree with the terms and conditions of using this weight loss program.

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