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ORDER
INFORMATION
Check
the appropriate boxes:
__ Diet Analysis
$29.99 __ Nutritional
Assessment $29.99
__ Special Package (includes both of
above products)
$49.99
__ Entire Fitness Package (includes
the above PLUS personalized
menus and
online support for 3 months)
$99.00
Note:
If ordering the Diet Analysis, please
submit 3 days of food intake.
If ordering the Nutritional Assessment,
the Special Package or the
Entire
Fitness Package, please complete the
following:
Ht:____ft____in
Wt:____lbs Age:______
Sex____M____F
Waist/measure:____in Hip
measure____in Goal weight: _____#
Activity
Level:_____Sedentary _____Somewhat Active ____Active
Special Considerations: (include any dietary concerns like diabetes,
heart disease, allergies)_________________________________________
Are you
willing to increase exercise? Y___ N___
Do you
have a time line for weight loss goal? Y___ N___ If Y, when?____
If paying
by check, please mail completed form with check to Nutrilink, 380
CJC Hwy, Suite 2, Cohasset, MA 02025. If paying by credit,
please complete section below by mail, FAX (781-383-9310) or email
(www.nutrilink.info - download the page, edit and email as an attachment).
CREDIT INFORMATION
NAME:
________________________________________________________________
ADDRESS:_______________________________________________________________
CITY:_________________________________STATE:_________ZIP
CODE:__________
TELEPHONE:____________________EVENING
TELEPHONE:___________________
BILLING
ADDRESS
ADDRESS:_______________________________________________________________
CITY:________________________________STATE:_______ZIP
CODE:_____________
CREDIT
CHOICE
MC______
VISA______
AMERICAN EXPRESS_______
16
DIGIT CARD NUMBER: _ _ _ _ -_ _ _ _-_ _ _ _- _ _ _ _
EXPIRATION
DATE ON CARD: MONTH______YEAR_______
LAST
3 DIGITS OF CARD CODE (on signature line on back of card)__ __ __
NOTE:
Credit card authorization takes 3-5 days. Your order will be processed
upon receipt of payment.
Download
and email this page to www.nutrilink.info or FAX it to 781-383-9310.
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