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Free Health Consultation - Let us help you!
Let us assist you in selecting the nutritional and/or personal care products that may help you. All information submitted will remain private and confidential.

What are you looking for in your search for good health?

Weight Loss		Health Improvements
Weight Gain		Skin Improvements
Weight Maintenance

If looking for weight management, how much weight are you serious about losing/gaining?

Weight to Lose / Gain:	kilos pounds stones
Your Current Weight:	kilos pounds stones
Your Height:	feet/inches cm
Your Age:	years

Do you suffer from any of the following diet related ailments? (choose all that apply)

Acne
Allergies
Arthritis
Asthma
Bronchitis
Burns
Cancer
Candida
Cellulite
Cholesterol
Chronic-Fatigue Syndrome
Circulatory
Colitis
Constipation
Crohns Disease

Depression
Diabetes
Digestive
Diverticulitis
Eczema
Fibromyalgia
Gall-Stones
Gas
Gout
Headaches
Heartburn
Hepatitis
Hiatus-Hernia
High-BP (Hypertension)
Hyperactivity (ADD or ADHD)

Hypoglycemia
IBS (Irritable-Bowel Syndrome)
Kidney-Stones
Low-Energy
Lupus
MS (Multiple Sclerosis)
Menopause
Menstrual
Migraines
Muscle-Tension
Osteoporosis
PMS (Premenstrual Syndrome)
Pain
Poor Health
Respiratory

Sleeping-Disorders
Spasms
Stress
Surgery-Recovery
Thyroid
Triglycerides
Ulcers
Urinary/Bladder
Varicose-Veins
Weak Immune System
Yeast-Infections

If required, check the boxes that best describe your skin. (select those that apply)

Dry / Sensitive	Normal / Combination	Oily
Fine dry lines around eyes and mouth, dehydration lines on face.	Slightly oily sheen on T-zone area - Not extreme.	Oily sheen on T-zone area and cheeks.
Cheek area is dull, dry, taut.	Drier cheek area.	Enlarged pores and blackheads evident.
Skin is very sensitive to sun, wind and pollution.	Occasional pimples and spots.	Pimples and spots frequent.

Please enter the following contact information.

Name:
Email Address:
Phone - Day:	(please include full area code; preferably a land-line)
Phone - Evening:
Postal Address:	(we can send information via mail)
Town / City:
State or Area:
Zip / Postal Code:
Country:
Please indicate the best day / time to contact you:
Contact Option 1:	(e.g. Mon - Thur between 12pm - 5pm)
Option 2:
Option 3:

Would you like to receive our product newsletter?

Are there any additional comments you wish to add to aid our evaluation of your health needs?

Please submit your results.

Your contact consultant is:
Name:	Penny Birchmore
Phone:	1800 178 214 or 0429 358 660
Email:

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Pay securely with major credit cards. Accepted Cards: Visa, Mastercard, Amex
We also take Direct Bank Deposit, Money Order or Cheque. All options available through checkout.
Products Available in Australia, New Zealand, United States, Canada

Updated: 24-Jun-2008
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