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Medifast wants to hear YOUR success story.

Tell us how you have become yourself with Medifast and we may use your story in advertising, media outreach, and marketing materials!

Please note: You will be instructed to upload before and after photos. Please have these photos ready prior to filling out the entire form. Be as detailed as possible in the sections below, and make sure to provide any information relating to your success on the Medifast Program.


OFFICIAL ENTRY FORM


Tell Us About Yourself

* = required field

First & Last Name *

 

Date of Birth *
 

Email Address *

 

Phone *

City *

 

State *

Zip Code *

 

Your Occupation *

 

Married? *

   

Have Children? *

   

 

Your Gender: *

   


Your Weight-loss Details

Weight-loss Start Date *
 

 

Weight-loss End Date *
 

Have you reached your goal? *

   

 

Did you lose weight with Medifast Direct online, a Take Shape For Life Health Coach, at a Medifast Weight Control Center, or with a Medifast Healthcare Provider? *

Your Starting Weight *

 

Your Current Weight *

Starting Dress/Pants Size

 

Ending Dress/Pants Size

Height *

 

Do you have any medical issues prior to your weight loss? *

     
     
     
     


Your Personal Weight-loss Experience

What was your motivation to lose weight? *

How did being overweight impact your social/work life? *

Have you tried other diets? *

Why did you choose Medifast? *

When did you first see results? *

How did others respond to your weight loss? *

Did you see any health improvement after losing weight? *

How has your life changed after losing weight with Medifast? *


How did you hear about Medifast?

   
   
   
   
   
 


Upload Your full-body Before and After Photos *

Before Photo *

After Photo *


Medifast Testimonial Release

On this day the undersigned, being of lawful age and having every right to contract in my own name is this regard, hereby gives to Medifast, Inc. their permission or upon their authority, and all persons and corporations for whom they are acting, the absolute right and unrestricted permission to use, publish, and/or copyright my testimonial statement and or excerpts thereof, describing my satisfaction with the Medifast, Inc. program in conjunction with still photographic portraits and/or pictures of me, single or multiple, and /or video footage of me. Or in which I may be include in whole, part or composite, or distorted in character or form, in color or otherwise, made through any print media for art, advertising, television, trade or any other lawful purpose, and in conjunction with my own name, in script, print, signature, facsimile signature or other form. I hereby waive any right that I may have to inspect and approve the finished product or the advertising copy that may be used in conjunction therewith, or the use to which it may be applied.

I hereby release, discharge and agree to hold harmless Medifast, Inc. and it wholly owned subsidiaries their nominees or others for whom Medifast, Inc. and its wholly owned subsidiaries are acting, from any liability arising out or unintentional blurring, distortion, optical illusion or other alteration or change that may occur or be produced in the taking of a said portrait, picture, or video footage or in any processing tending toward the completion of the finished product, unless it can be shown that said reproduction was maliciously caused, produced and published for the sole purpose of subjecting to scandal, reproach, and scorn.

I hereby agree and understand that the terms of this Testimonial Release are contractual and not a mere recital and further that I have read the forgoing Testimonial Release and fully understand it.

Please select today's date *