Enquiry Form
Thank you for your interest in joining Active Pacific, we are excited to learn more about you! Please fill in this form so we can gather a little more information to come up with a plan especially for you.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Country Code
Phone Number
Instagram Handle
What goal are you looking to achieve with your Health & Fitness?
*
Why are these goals important to you?
*
What has stopped you in the past from achieving this goal ?
*
If we guaranteed you'd drop 10kg in the next 3–6 months, what weekly investment would you be comfortable making to achieve that result?
*
$50-$85 per week
$85-$100 per week
$100-$130 per week
What is your preferred availability for a quick consultation call?
*
eg. Monday's after 5pm
Is there anything you would like to add?
*
Have you ever been diagnosed with Diabetes? (Type 1 or Type 2).
*
Yes
No
Have you ever been diagnosed with Hormonal or Reproductive conditions?(PCOS, endometriosis, thyroid issues).
*
Yes
No
Have you ever been diagnosed with Heart disease or High blood pressure?
*
Yes
No
Have you ever been diagnosed with Liver or Kidney disease?
*
Yes
No
Have you ever been diagnosed with Gastrointestinal disorders?(IBS, Crohn’s, coeliac, etc).
*
Yes
No
Has your doctor advised you to get medical clearance before changing your diet or exercise?
*
Yes
No
How did you hear about Active Pacific?
*
Submit
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