Harbor Athletic Club

Harbor Weight Loss Program Interest Sheet

Please submit this form and one of our weight loss representatives will respond within 3 business days.

Thank You for your interest!

Name *

Email *

Confirm Email *

Home Phone

Times to call Home

Work or Cell Phone

Times to Call Work/Cell

Are you a Harbor member? Yes No

Do you have Unity Health Insurance? Yes No

Amount of weight you would like to lose?

Number of years that you have been trying to lose?

Are you currently engaging in an exercise regime?

Available appointment times

Interests, Goals & Health Concerns

Security Code

Thanks for your interest in Harbor Weight Loss.

One of our weight loss representatives will respond within 3 business days.