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Book a free Wellness Evaluation ONLINE - get back in SHAPE & Lose Weight
We focus on Best Results ! Get your Free Body Goals Online Wellness Evaluation PLUS your BMI Calculator - It is Quick and Easy -
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1
Shape Up Program System to Lose as much Weight as possible in 10Days
(Tick all relevant for wellness recommendations for you. [ also claim FREE BMi ])
I am a FEMALE
I am a MALE
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2
How old are you
20 - 29 Years old
30 - 39 Years old
40 - 49 Years old
50 Years and Avove
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3
Where is your energy levels NOW, on a scale of 1 to 10?
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4
How Many Times Do you Eat Each Day ?
1 Meal
2 Meals
3 Meals
3 + Meals PLUS +
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5
How Many Glasses of Water do You drink Each Day ( Where each glass is 250ml of Water )
0 - 2 Glasses
3 - 5 Glasses
5 - 8 Glasses
8 + or more
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6
What is Your Activity Level ? ( How often do you Work out - x1 workout consists of minimum 30 minutes or more ? )
Inactive/Sedentary 0-1 Days per week
Moderately Active 1-2 Days per Week
Active 3 Days per Week
Very Active 4 or more days per week
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7
What programs / products have you tried in the past?
*
This field is required.
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8
My Main Goal is ( Mention All Relevant )
*
This field is required.
Your Health and Wellness Priorities:
Healthy Living
Weight Loss
Weight / muscle GAIN / Improve Sport performance
Just to get rid of Belly / Tummy
Improve Skin Tone
Extra income / Cheaper Food Option - tell me more
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9
How Much Weight are you looking to Lose (or Gain ) ?
* 1 - 5 kg
* 5 - 10kg
* 10 - 15kg
* 15kg +
* Just the Tummy Area
* 1 - 5 kg
* 5 - 10kg
* 10 - 15kg
* 15kg +
* Just the Tummy Area
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10
What is your Current Weight in KG and your Height in CM ?
I ask this question to be able to offer the right wellness recommendations for you. & This will Display your current BMi.. See your BEST E-mail For Normal Weight Ranges (Body Mass Index )
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11
What's Your Name
*
This field is required.
First Name
Last Name
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12
What is your WhatsApp Number
*
This field is required.
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13
Your BEST Email
*
This field is required.
example@example.com
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14
Which Area and Province do you stay ?
*
This field is required.
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15
I am Serious about My Results ! Please discuss Budget options . I can Spend the following amount per month
*
This field is required.
Tell me How I can SAVE Money on your Program
R530 to R890
R890 - R1220
R1220 - R1750
Tell me More about Your Discount Options
Other
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16
My Partner would also be interested.
See their Name and WhatsApp number below
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17
I would be Ready to start a Program and be Financially Ready by this Date !
*
This field is required.
-
Date
Year
Month
Day
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