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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
A 5 1
  US $ 95   (Or Eqvt Indian Rs)
B 10 2
  US $ 150 (Or Eqvt Indian Rs)
C 15 3
  US $ 205 (Or Eqvt Indian Rs)
D 20 4

  US $ 260 (Or Eqvt Indian Rs) 

S* -- --
  US $ 20   (Or Eqvt Indian Rs) 
S*:- Indiadiets Special Offer [Program S]: Only for those who wish to maintain their already perfect figure / physique  and good health by inculcating proper food habits and dietary regulations. For details 

Maintenance is a part of the individual program, with no extra charges
International Shipping through UPS / Aramex Couriers
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 ihp@indiadiets.com

 

 
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