New Enquiry
The 1:1 Diet with Lindsey Cummins
A little bit about you
Please answer the questions below so that I can gauge how’s best to support you to achieve your weight loss goals
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Day
-
Month
Year
Date
Lifestyle and Medical
These answers help me to recommend the best plan & step for your journey
Please Enter your Height
Please enter your approximate Weight
Please enter your waist measurement
Your Occupation
Please indicate your level of Activity
Please Select
Sedentary
Moderately Active
Very Active
Do you take any prescribed medication at all? If so please give names and dosage (Please put NONE in the box if not applicable)
Do you have any ongoing medical conditions? If so, please give details (Please put NONE in the box if not applicable)
Do you have any allergies or intolerances? If so, please give details (Please put NONE in the box if not applicable)
Have you had any general accidents or any surgery in the last 3 months?
Please Select
Yes
No
Women only: have you given birth in the last 3 months?
Please Select
Yes
No
Women only: are you currently breastfeeding?
Please Select
Yes
No
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.
Use this space to note anything else you think I should know or if you have any questions ahead of your appointment.
Space expands so type away!
Privacy Notice
As a result of a revision of the Data Protection Act 1998, the new General Data Protection Regulation (effective from 25th May 2018) requires that Consultants and The 1:1 Diet by Cambridge Weight Plan ensure that clients are aware of what personal data we hold, how we collect that data and with whom it is shared with and clients’ rights concerning their personal data. The Data Controller: Lindsey Cummins Personal information held for each client consists of your name, date of birth, address, contact telephone numbers, an email address, personal details and finally information on any medical conditions or medications that may relate to you. This information is collected during your first appointment. It is written on your confidential Personal Record Form (PRF), which is held in (insert here where your PRFs are stored), or held electronically on the secure electronic Personal Record Form (ePRF). - Your personal information is used for the following purposes, which form the legitimate legal basis of processing your data:- Protecting your vital interests – your medical information needs to be collected in order to ensure it is safe for you to purchase The 1:1 Diet by Cambridge Weight Plan products and for us to inform your GP that they may wish to monitor your medical condition or medications where applicable whilst you are following The 1:1 Diet by Cambridge Weight Plan programme. - The legitimate interests of the business – i.e. your personal details are required in order to keep in contact with you during your weight loss journey, without retaining your contact details we would not be able to contact you to supply you with the products you require or to ensure you are following the correct The 1:1 Diet by Cambridge Weight Plan Step. - Where you have chosen to consent to your Consultant contacting you regarding your weight loss journey, promotions or business opportunities you are consenting to your information being retained for the purposes of contacting you. However, where additional consent has been supplied you understand that you can withdraw your consent at any time by emailing lindsey.cummins@hotmail.com. This may however limit our ability to contact you regarding important The 1:1 Diet by Cambridge Weight Plan news or your weight loss journey. Your contact details are shared with: I do not share your data with anyone. Personal information such as height, weight and medical condition is NOT shared with anyone else apart from me, your Consultant, The 1:1 Diet by Cambridge Weight Plan and any medical professional as required. Where your information is passed to a third party we confirm that this information will be passed securely and only where it is necessary. The third party will not pass your personal data on to anyone else without your consent and they will only hold your personal data for the amount of time that there is a legitimate reason to process and hold your data. Personal data is held and kept for two years after you leave. Any hard copies are securely disposed of after this time. As a data subject you have the right to request access to and rectification or erasure of your personal data, to object to or request restriction of processing concerning the data, or to the right to data portability. You also have the right to object to automated decision making – if this happens you may request that an individual review’s your personal data before making a decision. In each case a request must be put in writing by email to me at Lindsey.cummins@hotmail.com As the data subject you have the right to make a complaint directly to a supervisory authority within your own country. Your Consultant and The 1:1 Diet by Cambridge Weight Plan’s data protection compliance is supervised by the:Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire, England, SK9 5AF Published: 03/12/2012
Client Declaration
1. The information given is correct and I have been advised to consult my GP before starting any weight loss programme. 2. I understand the importance of following the selected Step according to the directions given by my consultant and additional literature supplied by CWP. 3. If my health status/medication changes whilst using any CWP step, I agree to notify my consultant. 4. I understand that there is a legitimate interest in CWP and my Consultant holding the data on the Personal Record Form in conjunction with my use of the programme. I understand it may be necessary for you to provide data to medical professionals and vice versa in relation to me starting the Programme and that it is the vital interest which forms the legitimate basis for processing. 5. I am aware that it is my responsibility as a client to have regular medical reviews with my GP to assess any medication adjustment. 6. I have been supplied with the relevant CWP booklet and CWP privacy notice by my consultant and I have read and understood these prior to completing this form.
Please tick to confirm
I have read, understood & accept the Privacy Notice & Client Declaration.
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