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Indiadiets Health Perfect (IHP): The weight loss programs

Membership Form
This data is essential for our Nutritionists  at Indiadiets.com to plan out your personal Diet plan. Please fill up all the details correctly. 

Assurance: We at Indiadiets.com assure you that this data will be kept completely confidential and will be utilized solely towards the personalization of  your Weight Reduction/Gain Programs 

PERSONAL INFORMATION
Name in full :
Program
Duration
(weeks)
Maintenance
(months)
Charges (1USD=INR 62 or Current Rate)
A 5 1
  US $ 95  (Indian Rs. 5890 )
B 10 2
  US $ 150 (Indian Rs. 9300 )
C 15 3
  US $ 205 (Indian Rs. 12710 )
D 20 4

  US $ 260 (Indian Rs. 16120 )

S* -- --
  US $ 20   (Indian Rs. 1240 )
S*:- Indiadiets Special Offer [ Program S ]: One time Diet Chart. Only for those who wish to maintain their already perfect figure / physique and good health by consciously following proper food habits and dietary regulations. For details >>

Maintenance is a part of the individual program, with no extra charges
The prices are inclusive of Postal / Courier charges for sending the IHP Diet Package
Referral :
Sex :
Male Female Age:  

Height :
Weight :
Occupation :
Marital Status:  
Problem areas of fat distribution / Max. fat is located on:
( mark applicable areas if any else leave blank )
Chest Thighs
Upper Abdomen  Calves & Ankles
Lower Abdomen All Over
Hips
Smoking:
Yes No Occasionally
Drinking:
Yes No Occasionally
Do you exercise?
If yes, what type & how often:
Food Allergy / Body Ailments / Medical History (if any)
History of Obesity: (Optional)
Food Habit :
Veg Non-Veg Occ. NV.
Eating Speed :
Slow Normal Fast
Main Meal :  
Peak Hunger :
(Which part of the day do you crave most for food)
Water intake :
Approx. Present Meal Pattern (Based on what you normally eat or like to eat)
Breakfast +
Mid Morn :
Lunch :
Tea :
Dinner :
Milk :
(per day)
Address :
 (optional)
Country :
Telephone No :
E-Mail :
Read this membership form and if you agree proceed on to click the "Submit" button to enroll in the program.

In case of any doubts / clarifications please mail dietcounsellor@indiadiets.com

 

 
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