RBL Wellness Hub Registration

Registration Wellness Hub app

For Registered Employees ONLY
Please read carefully before proceeding:
We ask for your name, email, and phone number on this registration form so our health team can personally support and guide you on the Wellness Hub app. This information is only used for private communication with our wellness professionals and will never be shared with your employer or used for marketing. Your details are kept completely confidential and protected under HIPAA, GDPR, and data privacy laws.
Name*

First NameLast Name
Gender*

MaleFemale
Phone Number*
Please enter a valid phone number.
Email (use official company emails where applicable)*
example@example.com
Date of Birth*

DayMonthYear
Date
Residential Location*
General work Location*
Purpose

This assessment is designed to help us gain insight into your personal health and wellness needs. Your responses will assist our team in providing tailored support and guidance if required. All information shared will be kept strictly confidential.
Please answer the following:
1. How would you describe your overall health?*

ExcellentGoodFairPoor
2. What are your main goals for using the Wellness Hub app and it's many services?*

I want to improve my overall health and body composition.I want to reduce visceral (inflammatory) fat and lower my risk of chronic diseases.I’m looking for support from expert health professionals.I want to boost my mood, energy, and sleep quality.I’m excited to connect with colleagues and be part of a supportive community.I want to access exclusive wellness resources, prizes, and discounts.Other
3. Do you have any medical conditions or physical limitations?*

NoDiabetesHypertension (high blood pressure)AsthmaArthritis/Joint or Back IssuesHeart diseaseChronic obstructive pulmonary disease (COPD)DepressionAnxiety disordersObesityChronic kidney diseaseOther
4. How would you rate your current level of physical activity?*

Very ActiveModerately ActiveOccasionally ActiveNot Active
5. Are you experiencing any ongoing physical symptoms or discomfort?*

NoChronic Fatigue or Low EnergySleep DisturbancesUnexplained Weight ChangesShortness of BreathChest Pain or PalpitationsJoint or Muscle PainDigestive IssuesHigh Stress, Anxiety, or Mood SwingsFrequent HeadachesDizziness or LightheadednessOther
6. On average, how many hours of sleep do you get each night?*

Less than 4 hours4–5 hours6–7 hours8 or more hours
7. How comfortable are you using online tools like Google or ChatGPT to find health information (e.g., symptoms, medication, or healthy habits)?*

Very comfortable – I use them often and can find reliable informationSomewhat comfortable – I use them but sometimes unsure if the information is accurateNot comfortable – I rarely use these tools or find them confusingI do not use Google, ChatGPT, or similar tools for health information
8. Do you feel you have access to healthy food options at work or nearby?*

YesNoOther
9. Do you cook most of your meals or rely on convenience/processed foods?*

YesNoOther
10. Are you up to date with routine health screenings (e.g., blood pressure, cholesterol, dental, vision)?*

YesNoOther
By joining the Wellness Hub app, I agree to participate in the program to support my health goals. I understand that I should consult my doctor before participating, especially if I have any medical conditions, and will stay within my personal limits.I consent to providing basic personal information (name, contact details, weight, waist circumference) only for the challenge, with full confidentiality under HIPAA, GDPR, and privacy laws—this information will not be shared with my employer or unauthorised parties. I agree to the Build & Burn Challenge weigh-in and weigh-out measurements, including Bioelectrical Impedance Analysis (BIA) for body composition tracking and/or the use of the Wellness Hub app if I sign-up for it. Any optional activities, like sharing updates or photos, are completely my choice. I commit to safe, evidence-based weight management and will avoid crash diets or unproven supplements. I understand the use of the Wellness Hub app is not a substitute for medical advice or treatment.*

YesNo
Choose a Package:
prevnext( X )
3-month Wellness Hub3 MONTHS Reg. Price $249
99.00TTD

6-month Wellness Hub6 MONTHS Reg. Price $499
199.00TTD

Total

0.00TTD
Payment
Payment Options
💳 Bank Transfer
Account Name: Patient Connect Ltd
Bank: RBL Gulf View (Chequing)
Account #: 740801267201
👉 Please enter your full name in the payment reference so we can identify your transfer.

📲 WiPay
https://tt.wipayfinancial.com/scan2pay/virtualwellness
👉 Be sure to enter your name when completing the transaction.
Intellectual Property and Copyright Warning

The content, format, and design of this assessment form are protected by intellectual property and copyright laws. Unauthorized reproduction, distribution, or use of this material, in whole or in part, without explicit written permission is strictly prohibited. This form is intended solely for its designated purpose as a health assessment tool for employees and may not be copied, modified, or repurposed for commercial use. Any violation of these terms may result in legal action. If you wish to use this material for other purposes, please contact the rightful owner for permission.
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Registration Wellness Hub app

Please read carefully before proceeding:

Purpose

Please answer the following:

Payment

Intellectual Property and Copyright Warning