New Enquiry Form

Thank you for choosing me..... You won't regret it.

Before we start..... I need to get your important information.

Once you complete this I will call you to arrange everything else to start you on your journey
A little bit about you

Please answer the questions so that we can best help you achieve your goals. (The data you provide is completely confidential)
Name*

First NameLast Name
Address*

Street Address Line 2

Town/CityState / Province

Postcode
Phone Number *
Email*
example@example.com
Date of Birth*

DayMonthYear
Date
Have you done the 1:1 Diet/Cambridge Weight Plan before*

YesNo
Lifestyle and Medical

These answers help me to recommend the best plan for your journey
Height:*
Approximate Weight:*
Target Weight / Size*
Current Waist Measurement In Inches *
Your Occupation:*
Please indicate your level of Activity*
What are your motivations for losing weight now?*
Do you take any prescribed medication at all? If so please give names and dosage.
Do you have any ongoing medical conditions? If so, please give details
Do you have any allergies or intolerances? Yes or No If so, please give details*
If you are on any medication please state your Doctors details - name and address *
Have you had any general accidents or any surgery in the last 3 months?
If yes please give details
Have you been on GLP1 in the last 3 months?
If yes please give details
Use this space to note anything else you think I should know or if you have any questions prior to booking an initial consultation
Space expands so type away!
Women only: Have you given birth within 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 dependent on alcohol, substance misuser, underweight, pregnant, breastfeeding, or who have given birth within the last 3 months, and those under 14 years.
How did you hear about?*
* If Recommended by a friend or if you have an introductory offer code please state name or word below
By submitting you agree to below

I certify that the information submitted above is true and correct to the best of my knowledge

I consent to being contacted regarding commencing The 1:1 Diet by Cambridge Weight Plan by myself Leesa

I am happy for contact by phone / text (WhatsApp) and zoom or video chat and Email.

I am happy with photos taken to be used in the support group. Photos on SM will have faces blurred out, unless you wish to share your own progress

I agree that any physical consultations without purchasing products for my step will have a £10 consultation charge.

Missed Physical Appointments - £10
Signature *

Powered by Jotform SignClear
Should be Empty:

A little bit about you

Lifestyle and Medical