Weight Loss Application

This is an application for our Weight Loss program with SOMA MD and Julia Chien, Registered Dietitian.

To better understand your goals, we would love for you to fill out this short application. Once we receive your application, we will reach out shortly for the next steps!

Email *

Full Name *

Phone *

Birth Date *

Please provide a brief description of your medical history *

Do you have a weight loss goal? *

What are your top 1-3 health goals right now? *

What is your current weight & height? *

What do you feel like you need from SOMA MD and Julia Chien RD to achieve these goals? *

What are your 3 biggest challenges with achieving your weight loss/health goals? *

What are you expectations joining SOMA MD's Weight Loss program? *

Sustainable weight loss requires consistency, commitment, and time with the nutrition and treatment plan. How ready are you to invest in yourself? Please note: This is not a rapid or short term weight loss program. *

I Agree

Thank you! We will be in touch in the next 24-48 hours!

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A staff member will contact you to confirm details. Please allow 48 hours for a response.

SOMA MD in South Surrey

Address. 2411 160 St Suite #200, Surrey, BC, V3Z 0C8 | Phone. 604-969-7911 | Email. hello@somamd.ca

SOMA MD is located in beautiful South Surrey, in the Grandview Corners, Grandview Heights area — corner of 160th Street and 24th Ave.