The 1:1 Diet with Clare
Takes 2 minutes. I’ll send the best option for you after 🤍 (All information provided will be treated in the strictest confidence.)
Your Full Name
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First Name
Last Name
Male/Female
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Male
Female
Your mobile phone Number
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Enter Your Phone Number
Format: 00000000000.
Your E-mail
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example@example.com
D.O.B
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/
Day
/
Month
Year
Preferred way of communication
Please Select
Whatsapp
Email
Any
Occupation
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Typical weekly activity /exercise
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Your Weight
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Your Height
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Your target weight
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Do you have any medical conditions/take any medication, or have any allergies or intolerances that I should be aware of before recommending a plan?
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Yes
No
If yes, please give brief details:
What level of support would suit you best?
Full 1:1 support
Light-touch (monthly check-ins)
Just access to products
What would you like me to send you next?
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Price list (self-led / maintenance option)
Full 1:1 support information
Not sure yet
Address
Number and Street Address
Street Address Line 2
City
Postal Code
I’m happy to be contacted with recommendations, offers and updates
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Yes
No
I am interested in potentially becoming a consultant one day and would like to discuss this
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Yes
No
Client Declaration Please confirm the following and tick the box to agree with the 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 directions given by my Consultant and additional literature supplied by CWP. 3. If my health status/medication changes while using any CWP Step, I agree to notify my Consultant. 4. I understand that there is a legitimate interest in CW 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 this is a 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 adjustments. 6. You will be 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. Client agreement I agree with the above statements
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Signature
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I declare that the information given is correct. I consent to my Consultant contacting me at any point regarding my weight loss journey.
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