First and last name *

Sex? *
FemaleMale

How old are you? *
-less than 18181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697070+

Body mass (kg) *
-less than 6060616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160+more than 160

Body height (cm) *
-less than 150150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210210+

Body shape
applepearhourglassbananadon't know

Please answer the following questions about your eating habits

Your eating style is described by the statement: *
Choose one of the offered optionsI try to eat healthyHealthy in the morning, everything in the eveningI often have healthy mealsI eat whatever I wantI don't think about itI'm often on a diet

How often do you eat*
choose one of the optionsonce a daymorning and eveningI have regular mealsI only eat dinnerI eat something all the timeI rarely eatnone of the above

I'm having breakfast... *
Yes, I always have breakfastI eat something smallSometimes I have breakfastI never have breakfast

I feel hungry... *
Very oftenYes sometimesNo, neverI rarely eat something

I eat meat... *
Yes, oftenSometimesRarelyNo, never

I eat vegetables... *
Yes, oftenSometimesRarelyNo, never

I eat fruit... *
Yes, oftenSometimesRarelyNo, never

Dairy products... *
Yes, oftenSometimesRarelyNo, never

Candies... *
Yes, oftenSometimesRarelyNo, never

My main daily meal is: *
Choose an answer...BreakfastLunchDinnerSnackLate mealI don't knowI don't know

I'm on a diet... *
Choose an answer...Yes, often on a dietYes, I am currently on a dietSometimes I am on a dietOnce upon a time...No, never

Health condition

Do you have health problems?

What is your goal with the liposuction diet?? *
Choose an answerI want to lose weight quicklyI want to improve my appearanceI want to improve my healthAll of the aboveOther reasons

ARE YOU READY TO ACCEPT THE 14-DAY CHALLENGE?*

Do you want to try the liposuction diet? *
Select an answerYes, I want to try the liposuction dietI still don't know, I need more informationNot for now, I'm just curious

If you accept the 14-day challenge, the first step is a conversation with our nutritionists, which can also be done over the phone. Enter your number below and we will call you at a time that suits you.

Place *

Phone number

How would you like to get in touch?
Choose optionsI want a telephone consultationI want a consultation via e-mailI want to make an appointment for a personal consultation

Email *

Your message

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