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New to Herbalife?

Congratulations on taking the next step to weight loss and improved health. If you are ready to lose weight for the last time, we are ready to help you! By answering the following questions we can better assist you with your weight loss needs. All information you provide to us is strictly confidential. One of our top weight loss consultants will be contacting you within the next 24 - 48 hours to customize a program just for you!

Are you serious about changing your weight now? Yes! No
Name :	*(Your first name)
Lastname :	*(Your last name)
Address :	(Street name, nr. etc.)
City :	Zip: *(City and Zip or postal code)
Telephone day :	*(Number during office hours)
Telephone evening :	*(Home phone number)
Cell :	(Cell number)
Email :	*(Your e-mail Address)
Best time :	(When is the best time to contact you)
Age :	*(Your age)
Height :	*(Your Hight.)
Weight :	*(Your weight.)
If you would like to loose weight, How many pounds do you want to loose?
What have you tried before and how did it work for you?
What is the reason why you want to lose weight now?

Do you have any other health concerns?
How many meals do you eat a day? 1 2 3 4 or more
How much money do you spend per meal? 1 2 4 6 dollars or more
When would you like to start?
How did you find this website?
Notes:
	We will get back to you with feedback and a personalized program that would fit you, If we need more information, one of our shapeworks consultants will contact you by phone.
	"Thank you for your Interest"

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