New Enquiry Form for The 1:1 Diet by Jane Victoria

Jane Victoria - The Feel Good Shack

New Enquiry Form
A little bit about you

Please answer the questions so that I can best help you to achieve your goals.
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

DayMonthYear
Date
What's your WHY? This is not just about losing weight, feeling healthier and fitting into smaller clothes - really have a think about why you want to lose weight now and share this me ...
Lifestyle and Medical

These answers help me to recommend the best plan for your journey
Please enter your Height
Please enter your approximate Weight
Do you have any Allergies/Intolerances or Dietary requirements
Your Occupation
Please indicate your level of Activity
Do you take any prescribed medication at all? If so, please give names, dosage and start date
Do you have any ongoing medical conditions? If so, please give full 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?
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.
Please let me know if you would like to attend my Feel Good Shack 'face to face' in Leamington Spa OR if you would like me to support you virtually with your products delivered to your home?
Space expands so type away!
Use this space to note anything else you think I should know or if you have any questions ahead of our chat ...
Space expands so type away!
Please verify that you are human*
Thank for completing this form I will be in touch with you soon.

If you have an questions meanwhile please do get in touch 07916 151045

Jane Victoria
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Jane Victoria - The Feel Good Shack

A little bit about you

Lifestyle and Medical