Free Weight Loss Consultation.
Free Weight Loss Consultation Survey
For a free consultation and to receive your personal maintainable weight loss program, please complete the following form.
Please ensure that you complete the mandatory fields. (Marked with “
*
” )
*
First Name
*
Surname
*
Email
Day Time Telephone No'
Evening Telephone No'
Mobile No'
(Please enter at least one telephone number)
*
Best time to call
Morning
Afternoon
Evening
Anytime
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Country
United Kingdom
Argentina
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Austria
Bahamas
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Beloruss
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Botswana
Brazil
Bulgaria
Canada
Chile
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Eire
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Finland
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Gambia
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Germany
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Netherlands
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Philippines
Poland
Portugal
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Other
Address Line 1
Address Line 2
City
Postcode
Age
Please select
Under 18
18 - 30
30 - 40
40 - 50
50 - 60
Over 60
Occupation
Which of the following statements applies to you?
You may select more than one.
I would like to lose weight
I would like to gain weight
I would like to maintain my weight
I would like to feel healthier
I would like more energy
I would like to feel more confident
I would like to look better
Have you tried any of the following programmes?
You may select more than one.
Weight Watchers
Slim-Fast
Herbalife
Slimming World
Rosemary Conley's Hip & Thigh Diet
Atkins Programme
Other (please specify)
What is your weight loss/gain goal?
Please select
0-3 lbs
4-7 lbs
8-14 lbs
14-28 lbs
28 lbs +
When are you looking to lose/gain the weight by?
Please select
ASAP - I'm serious and committed
0-4 weeks
4-8 weeks
8-12 weeks
3-6 months
6-12 months
Why do you want to lose/gain weight?
Please select
To look good
To have more self-confidence
For health reasons
I'm going on holiday
I'm attending a special event
Other (please specify)
If Other:
How much would you be prepared to spend per day to achieve your goal?
Please select
Less than £1.00
£2.00
£3.00
£4.00
£5.00
Which of the following health and beauty products do you buy regularly?
You may select more than one.
Weight Loss
Nutritional Supplements
Skin Care
Beauty
Anti-ageing
Where did you see our advert?
National Newspaper
Local Newspaper
Search Engine
Friends Recommendation
Flyer or poster
Other (please specify)
Home Page
Achieve Success
Easy To Use
Healthy Lifestyle
Personal Care
Free Consultation
Contact Me
“I couldn’t believe the money...
I saved on my food bill using this programme.”...
Kerry Ogden - Peterborough
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