Diet Chemistry : 10 Day Cor-Regimen
CONSENT FORM
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Email *
Name *
Age *
Sex *
Delivery Address *
Phone number *
Weight in Kgs
Medical History (For Example Diabetes, Hypertension etc)
General Info like stress/Acidity/Constipation Etc
On any regular medications like Blood Pressure/thyroid/PCOD/anxiety or depression etc
Food allergies
Dental Problems like bleeding gums, pain in gums/ tooth/teeth, swelling etc.
Covid-19 *
Kindly share your Covid-19 Test Report (Mandatory), Medical Prescription (if any) and Aadhar Card (Mandatory) on whatsapp number: 9717008415 *
Required
 I Miss/Mrs. /Master /Mr give consent to Diet Chemistry to provide counselling or diet and meal/meals to myself or the client for which I am legally responsible. If due to any reason I client do not continue the plan in that condition money will not be refunded. Your opted package is only valid for 10 days. No grace period is availabel. Only on medical grounds (with reports and doctors approval) if you discontinue your Cor-regimen, your package will be converted into maintenance diet plan.I agree to the above conditions. *
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