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Country Life Weight Loss Program
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Compliance
1
Full Name
*
This field is required.
First Name
Last Name
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2
Age
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3
Current Weight in Pounds
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4
How much weight (in pounds) would you like to lose?
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5
Do you have any diagnosed health concerns?
*
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None
Diabetes
High Blood Pressure
High Cholesterol
Heart Failure
Cancer
Other
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6
Please list any current medications with doses. (One per line)
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7
Do you have any current restriction, allergies, etc?
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None
Mobility
Hearing
Vision
Food Allergies
Other
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8
Phone Number
*
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9
Email
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example@example.com
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10
How did you hear about this program?
Select all that apply
Country Life Website
Flyer or Poster
Facebook
Other Social Media
A Friend or Family Member
Country Life Store Staff
Other
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11
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ORDER SUMMARY
Total cost
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Registration - Country Life Weight Loss Program
$
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Number of People Attending
First Name
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Credit Card Number
Security Code
Card Expiration
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