| Name: |
|
| Cell
Phone: |
|
| E-mail: |
|
| Comments: |
|
| Did
you watch the video
? |
Yes
No
|
| How
much weight do you want to lose? |
|
Do you need more energy?
|
Yes No
|
| How much do you spend on an
average meal? |
|
| Do
you have any children? |
Yes
No |
| If
so, how old are your children? |
|
Is
there anyone else in the household
who wants to lose weight too? |
Yes No |
| Do
you have any other health conditions ? |
|
| Please
contact me about: |
Losing weight, improving my health |
|
I would also like info about sharing these
prodcuts
with others and earning referral fees |
