Personalized Meal Plan for only $59

You are now one step closer to insuring your weight management goals becomes a reality!

Simply answer the following questions and we will customize your plan to remove the guess work out of many carbohydrates, proteins and fat calories you should be consuming to meet your goal. Once your form is completed and payment has been processed your meal plan with detailed instruction will be Emailed to you.

Submit your payment and then fill out the following form for your Personalized Plan

Select Your Meal Plan


First Name

Last Name

Date of Birth  (M/D/Y)   
   
 

Age

Address


City

State            Zip Code
 
 

 

Home  Telephone

Cellular Telephone

Work Telephone

Email

Gender

Male  Female  Pregnant?   months   

Height

    

Present weight

lbs    

Goal weight

lbs

Body fat %

  How taken:

Body build

   

Place your thumb and middle finger around your wrist.

Small = fingers overlap.    Medium = fingers touch.   

Large = fingers don't touch

Lifestyle / Profession

Rate your overall activity level of your profession:

Your goal

 

Body type

Which one BEST describes you:

 

Health & Medical condition

                                                     If other please explain:

 

Weekly exercise routine

Please include activity, days and times.

Foods you like

Foods you dislike

Have you ever been placed on any type of weight management program in the past:

NO   YES, please explain why and results:

  Any Additional information you would like to add:

 

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