New Enquiry Form: Rebecca and Julie

New Enquiry
Rebecca & Julie
A little bit about you

Please answer all questions so that we can best help you achieve your goals
Name

First NameLast Name
Gender*
Email
example@example.com
Mobile Number
Facebook user name
example@example.com
Instagram user name
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal Code
Date of birth
DD-MM-YYYY
Lifestyle and Medical

These answers help us to recommend the best plan for your journey
Please enter your height*
Please enter your weight*
Your occupation
Please indicate your level of activity
Have you done The 1:1 Diet before?
If the answer to the previous question was YES, how long ago was this?
Do you have any medical conditions?*
Please give details
Please state doctor’s name and surgery
Do you take any prescribed medication?*
Please list medications and dosage
Do you have any allergies/intolerances?*
Please give details
Have you read through the medical information notes above, particularly the contraindicated section? If any apply to you, please detail below. *
Please give details
Have you had any general accidents or any surgery in the last 3 months?*
Women only: have you given birth in the last 3 months?*
Women only: are you currently breastfeeding?*
What would your IDEAL weight be?
Tell us about your WHY - your reason for wanting to lose weight and what made you contact us today. This enables us to better support you when we have a true understanding of YOU 😘
NOTE: The 1:1 Diet by Cambridge Weight Plan is NOT appropriate for those who are alcoholic, substance misusers, underweight, pregnant, breastfeeding, or who have given birth in the last 3 months, and those younger than 14 years.
We understand that everyone’s needs are different and we adapt our support to best suit you whilst on plan. Whilst we are always available by phone/message to answer your queries as they arise, we like to check in with you from time to time, to see how you are getting along. Please indicate your preference:
Would you also like a telephone or video call at a pre arranged time each week?
How did you hear about us:
What made you choose us to be your consultants? PS we are so glad you did! 😘
Use this space to note anything else you think we should know or if you have any questions ahead of your appointment.
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New Enquiry

Rebecca & Julie

A little bit about you

Lifestyle and Medical