Accu Weight-Loss "The Bead Diet"

STEP 1: SUBMIT INFORMATION

Note: This page is for new clients who have already attended orientation. If you have not yet attended an orientation session, please see orientation for more information.

Orientation Attended (mm/dd/yy)
Phone Number Called FROM for Orientation	() -
Anticipated Start Date (mm/dd/yy)
Gender (M/F)
Title (Mr. Mrs. Ms. Dr., etc.)
First Name
Middle Initial
Last Name
Date of Birth (MM/DD/YY)
Shipping Address Line 1
Shipping Address Line 2
City
State
Zip Code
Country (if outside US)
Home Phone	() -
Work Phone	() -
Mobile Phone	() -
E-mail Address
Height (nearest 1/4 inch)
Current Weight (nearest 1/2 pound)
Desired Weight
Do you have diabetes (if yes, list meds)
Do you have high or low blood pressure (if yes, list meds)
Women, are you pregnant or breast feeding?
Do you have allergies to foods (if yes, please list)
Medical conditions now being treated (please list)
Current Medications (if any)
Describe current eating habits in a typical day (e.g., # meals per day, etc.)

Accu Weight-Loss "The Bead Diet"

all of our losers are winners

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