Please enable JavaScript in your browser to complete this form. - Step 1 of 4Name *FirstLastFacebook name *This is the name everyone sees, it maybe different from your facebook "username."Description of your facebook profile picture *Please provide a description of your profile picture, just in case other people have your same facebook name, we can more easily tell which is your account. Email Address *Mailing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextAre you pregnant? *YesNoSpecialty *What is your speciality?What year where you born? *Weight *What has been your most recent weight?GeneralsAnything in general you want me to know ahead of time? Any interests? And dislikes? MethodDo you have a weight loss method in mind already? Ex: calorie counting, portion control, low carb, keto, IF, weight watchers? Maybe a combo?NextAre you greater than 18years of age? *YesNoPlease know we may contact you if extra verification is needed. If we cannot verify your age you will not be enrolled in the Group. Verification of age will be done via state identification, for example driver's license. I certify that I completely understand this group is NOT offering me medical services and there are no Physician-Patient relationships within this group between me and the Group's Guide or me and other Participants. *YesNoIf you answer no please stop and do not enroll in the program. I certify that I am a current or retired(for any reason) Licensed Physician. Meaning I GRADUATED medical school, and started at least one day of Internship or Residency. *YesNoPlease know we may contact you if extra verification is needed. If we contact you and you are not able to verify the above you will not be enrolled, and a refund will be given. NextI agree to allow 3 total payment of $400 to be charged to this credit card for each 28 day cycle. Each charge occuring around day 1 of each cycle. *YesWPWI Accountability Group *Price: $ 400.00Total *$ 0.00Credit Card *Card NumberSecurity CodeName on CardExpirationMM123456789101112/YY2425262728293031323334Comment or MessageNameSubmit