(B) Customer Registration Form

Welcome to The 1:1 Diet by Cambridge Weight Plan
The Weighting Room
Your Contact Details:
Full Name*

First NameLast Name
Address*

House Name/Number

Street/Road Name

TownState / Province

Post Code
Phone Number*
E-mail*
Personal Details:
Birth Date*

DayMonthYear
Gender:*
Occupation:*
Height:*
Current Weight:*
Waist Measurement:*
Are you currently taking any medication?*
Do you have any allergies or intolerances?*
I confirm the above information is correct and if my health status or medication changes while I'm on The 1:1 Diet I will notify my Consultant.
Signature*

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Date:*
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Welcome to The 1:1 Diet by Cambridge Weight Plan