Herbal Weight Loss Australia - herbalife weight loss products and programs.

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Weight Loss Consultation

If you are serious about losing weight and improving your health, then please complete and submit the following consultation form. Please take your time in filling in the form, as this will aid the consultant in determining your personal needs.

Once we have received your information, one of our Herbalife consultants will contact you directly and go through the options available on the Herbalife program.
Herbalife weight loss products and programs

Herbalife weight loss products and programs

All information submitted will remain private and confidential.

* required fields

1).

On a scale of 1-10, how serious are you about losing weight? (10 being the highest)

* 1 2 3 4 5 6 7 8 9 10

2).

How much weight would you like to lose?

* kilos pounds stones

3).

What diets have you tried before ( please list )?

4).

How did they work for you?

5).

What are your main reasons for wanting to lose weight right now?

6).

Do you have a particular time-frame to lose the weight by? ( for a special event e.g. for a wedding in 4 months )

7).

What is your current age, weight, height and build?

Your Current Age:	( must be at least 18 years old )
Your Current Weight:	kilos pounds stones
Your Height:	feet/inches cm
Your Build:	Small Medium Large

8).

What weight would you like to be?

kilos pounds stones

9).

Do you suffer from any health issues? (e.g. digestive problems, bowel problems, diabetes etc...)

10).

Please enter the following contact information, so one of our consultants can contact you for your one-on-one consultation:

* Name:
* Email Address:
Day-time Phone:	(please include full area code; land-line would be best)
Evening-time Phone:	(please include full area code; land-line would be best)
Address:	(we can also send information via mail)
Town / City:
* State:
Zip / Postal Code:
* Country:
	Note: since we only have time to help genuine inquires, submissions with false contact details will be discarded. Please do not submit information on someone else's behalf.
Please indicate the best contact methods and time to contact you:

Best Contact Methods:	Phone Email Mail

* Best Contact Time:
If required, please specify a day / time range (e.g. Mon-Wed between 6-8pm):
Contact Option 1:
Option 2:
Option 3:

11).

On Herbalife there are different program options to help suit your personal needs, goals and budget.
To help us further in our recommendation what budget per week do you have for your health and weight-management?

Weekly Budget:

12).

Are there any additional comments you wish to add to aid us in our evaluation of your weight loss needs?

13).

* Please submit your details.

Once we have received your information, one of our Herbalife consultants will contact you directly and go through the options available on the Herbalife program.
Herbalife weight loss products and programs

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Last Update: 02-Sep-2008
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Herbal Weight Loss Australia - herbalife weight loss products and programs.