Copy/Paste onto Email and send:
Date:______________________ Referred by:_________________________________
NAME: ___________________________________________ DATE OF BIRTH: ___________________________AGE:_______ __________________________
ADDRESS: ______________________________________________________________________________________________________
TELEPHONE: ___________________________EMAIL ADDRESS: ________________________________CELL:__________________
MAILING ADDRESS:____________________________________________________________________________________________________
IN CASE OF AN EMERGENCY, NOTIFY: _____________________________________ TELEPHONE NUMBER : ______________________
Commitment Fee: YES: _______________ NO:___________________ (No: only entitles you to a gift certificate)
Health Facility Name and Location _____________________________________________________
Weight Loss Segment: 1)
January 12 - February 5, 2009 2) February 9, 2009 - March 5,
2009 3) March 9, 2009 - April 3,
2009 4)
Weight Now: __________________ Weight Goal:__________________ Dress Size Now:_________________ Dress Size Goal: _________________
Health: Diabetes Cholesterol High Blood Pressure At "Risk"
Other: Please specify:
Please consult your physician before beginning any weight loss program, project, or plan
ADDITIONAL INFORMATION
FUTURE GOALS: ________________________________________________________________________________
Suggestions: ______________________________________________________________________
Copy/Paste onto Email, Mail or Bring in:
2640 Ceaery Blvd., Suite 11, Jacksonville, Fl 32211