Keralty Clinics: Nutritionist appointment form
In order for us to process your appointment, kindly provide the following information:
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Personal and contact information
Your full name: *
Gender *
Your contact number: *
Make sure to enter an active contact number.
Your contact e-mail:
Make sure to enter an active e-mail address.
Your preferred schedule and clinic: *
Please state your preferred date and we will do our best to accommodate your requested schedule.
ALLOW US TO KNOW YOU BETTER
Fill out an initial nutrition screening form “Know Your Nutrition and Lifestyle score”
GOALS: What is your main goal related to health, nutrition, and fitness?
Clear selection
If "Management of health condition" above, please specify which one
GOALS: How determined are you in achieving these goals?
Lowest
Highest
Clear selection
NUTRITION. Based on your current lifestyle and food intake, please check those w/c apply:
LIFESTYLE. Do you smoke?
Clear selection
LIFESTYLE. Do you drink alcohol?
Clear selection
LIFESTYLE. How much do you sleep a day?
Clear selection
How did you know about us? *
This helps us improve the way we communicate with you in order to serve you better. There can be more than one answer.
Required
Data Privacy Consent
In order to process your request, we need you to consent to the processing of the personal information you have provided. *
The request of personal information on this online form is done with the sole purpose of processing and managing your  request. In accomplishing the information requested, you agree that Metro Sanitas Corporation and/or its subsidiaries or shareholder companies will process these Personal Information relating to you. Such processing of Personal Information may include its collection, recording, updating, modification, retrieval, use, and retention. You are also consenting to: 1. Making your Personal Information available to the relevant employees of Metro Sanitas Corporation, its subsidiaries or shareholder companies, and any service provider that may be involved in the process and management of this event; 2. The processing of your Personal Information for generating statistical data relevant to this specific activity; 3. The retention by Metro Sanitas Corporation of your Personal Information for the period necessary for the purpose of this request. We will dispose of your Personal Information upon the lapse of the Personal Data Retention Period in accordance with applicable laws and regulations. You are entitled to certain rights in relation to the Personal Information that may be collected from you, including the right to access, correction, and to object to the processing of the same. Your information will be held securely and will not be made available to third parties without your expressed consent. By checking the checkbox below, you hereby certify that you understand the foregoing and that you are giving your consent to the processing of your Personal Information and Sensitive Personal Information under the terms and conditions provided above.
Required
Confirm Form Submission
In order to complete your appointment request, click the SUBMIT button below. Please take note, however, that the availability of your requested schedule is not guaranteed. YOUR APPOINTMENT WILL BE CONFIRMED. A confirmation will be sent via email, including your Nutrition and Lifestyle Score. We will also send a link to a 3
day food diary. Please send any accomplished sheets one day before your
consultation schedule.
Submit
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