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Meal Plan Order Form
Fill out the form below to order your Dr Diet meal plan(s).
Meal Plan Order Form
Your name *
E-mail address *
Please double check your e-mail address!
You will be receiving an order receipt.
Contact number *
Gender *
Female
Male
Age *
Height *
Please specify in centimetres (cm) or feet (ft)
Weight *
Please specify in kilograms (kg) or stones (lb)
Goals of meal plan
Weight loss
Weight maintenance
Weight gain
Diabetes control
Blood pressure control (healthy heart)
Cholesterol control (healthy heart)
Muscle growth (strength athletes)
Endurance training assistance (athletes)
Current exercise routine *
Desired weight loss
Desired time frame for weight loss
Dietary requirements *
Please choose..
Regular diet
White meat only
Seafood only
Vegeterian
Vegan
Dairy free
Egg free
Wheat free
Diabetic
Heart patient
Wheat & Dairy Free
Meal plan option *
Please choose..
New Customer $60
Existing Client $50
For two $90
Follow-up Education $20
Seen as a Dr Diet client (month & year)
Medical Centre seen at
Payment Method
Account details will be emailed to you for a bank transfer. Credit card payments must be made via telephone.
Please choose..
Credit Card
Bank Transfer
Comments *
Terms & Conditions
Meal plans will not be sent until payment has been received. Electronic delivery of meal plans usually takes 3-4 days after receipt of payment however this is not guaranteed. By submitting this form I enter a legally binding agreement and am required to pay the full fee for a suitable meal plan. Results on a Dr Diet Meal Plan can only be guaranteed providing I do not have medical conditions or medications that may inhibit such a process and all details supplied by myself are true and correct. Information provided is a guide only and is in no way intended as medical advice. Dr Diet will not accept responsibility for any foods consumed that may cause a reaction for an allergy or food intolerant sufferer; those customers are responsible for checking ingredients lists themselves. Dr Diet has made every attempt to provide true and accurate information but will take no responsibility for possible ingredient changes to foods & products listed and any other information supplied. All information supplied by Dr Diet in any shape or form is copyright and no part of it may be reproduced or transmitted in any form without the written permission of Dr Diet.
I agree to the above terms and conditions *
Yes
No
Where did you hear about DrDiet?
Individuals & Groups
Meal Plans
Meal Plan Order Form
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