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Please complete this simple form for your free consultation allowing us to show you a guaranteed way to transform your life by achieving your wellness goals, receive FREE coaching, support & motivation
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Name
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First
Last
Email
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Phone Number
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Who reffered you to this consulation page?
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Which areas of your life would you most like to improve? Tick all that apply
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Improve Energy
Weight Loss
Healthy Aging
Improved Sports/exercise/workout performance and recovery
Better Sleep
Stress Management
Anti-Aging Skin Care
Improve Pet Health
Financial wellness
What are the specific health and wellness goals you would like to achieve
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Which diets/eating methods have you tried in the past?
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Keto
Paleo
Atkins
Intermittent Fasting
Weight Watchers
Slimming World
No Sugar
Other - please specify
Other - Details
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What supplements do you use and what is your average spend per month?
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Multi Vitamins
Plant Based Nutrition
Pre-Workout Sports Performance
Sports Recovery Products
Protein Shakes/Supplements
Energy Drinks
Probiotics
Slimming World/Weight Watchers Meals
Less than 50 per month
50 - 100 per month
More than 100 per month
Are there specific reasons for improving your health and wellness?
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Want to feel better
Want to look better
Want to be my best for a special occasion
Want to fit into my clothes
Medical reasons
Other - Please Specify
List of Medical Conditions
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List of Medications Currently Being Taken
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Do you have a past of current history of substance abuse? Please tick the relevent areas
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Alcohol Abuse
Recreational Drugs
Other Substances
Other - Details
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Further Information
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Food supplements should not replace a balanced and varied diet and a healthy lifestyle. Do not exceed recommended daily doses. Keep out of reach of children. For pregnant and breastfeeding women, and children, refer to a doctor's advice.
Xelliss® products are food and dietary supplements. They are not intended to prevent, treat or cure any disease or medical condition.
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