Personal Information Formadmin2023-07-31T06:24:49+00:00 Informed Consent Form & Terms for Nutritional Counseling I Miss/Mrs./Mr./Master/Dr. give consent to DIET CHEMISTRY (Gurleen Kaur) to provide Nutrition counselling to myself or the client for which I am legally responsible. In any of the condition. MONEY WILL NOT BE REFUNDED. IF ANY MEDICAL CONDITION KINDLY PROVIDE WITH REPORTS AND PRESCRIPTION OF THE DOCTOR. (In any of the stage you can only freeze or transfer your package). Your opted package is ONLY VALID for 1 month extra. After that grace period your package will DISCONTINUE. Name Mr/Miss/Mrs/Dr * Age * Sex * Height * Weight * Phone Number * Address * Email ID * Medical History Buisness/Job/Homemaker Business/Job Type Surgery Constipation/Acidity/Bloating Menstaration Cycle Stress/ Anxiety/ Depression Blood Report Nutritional Deficiencies Food Allergy Food Timings Food Addictions Food Dislikes Veg/Non-veg Water Intake Aerated Drinks Workout/ No. of steps Outings/Meals from outside Cheat Day Followed Diet Plan Before, If Yes, when and from whom Wake up time Sleep time Workout/ Excercise Time If working, Time when leave for work If working, Time when reach home If working, Lunch time Any other information to be added Package opted Reference Name/Relation I agree to all above mentioned conditions.
