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APPLICATION

Join the Wellness Club.

Stay up-to-date with our newest events,

seasonal specials, promotions, and health news.

APPLICATION

The form below is for 2025-2026 MAOF Fitness Clinic Wellness Program. Please enter your information and submit. One of our staff will contact you within 48 hours.

Today's Date

Phone *

Full Name *

Email *

Street Address

City

State

Postal Code

Postal Code

Postal Code

Sex

Female

Male

Marital Status

Single

Married

Widowed

Separated

Divorced

Date of birth

Height

Weight

Primary Care Physician

Is Medicare your primary insurance?

Yes

No

Have you ever been in a weight loss program before?

Yes

No

Do you have a scale?

Yes

No

Do you own a computer or Tablet?

Yes

No

Empowering Your Path to Wellness

Quick Links

Location: Virtual

Phone: 601.983.7494

Email: [email protected]