First Name *

Last Name

Phone *

Email *

If the program is a good fit for you, are you prepared to take the next step toward getting started? *

Yes — I’m serious and ready to get started

Yes — but I have a few questions first

I’m just researching my options right now

How much weight would you like to lose?

What best describes your biggest frustration?

Weight won't come off

I lose it but gain it back

Both

How would you like to work with Dr. Hassel?

In person (Clive, Iowa)

Remotely (Nationwide)

Either works for me

City, State (Optional)

Anything else you'd like Dr. Hassel to know? (Optional)

If you qualify, when would you like to get started? *

ASAP (this week)

Within the next 2 weeks

Within the next month

More than a month from now

Ready for the next step?
After you submit this form, Dr. Hassel will personally reach out to you by text to discuss your goals and next steps. Please submit only if you're genuinely interested in getting help and willing to respond when he contacts you.

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