Genderfm
Pregnantyesno
First Name *
Last Name *
Street/No. *
ZIP *
Phone *
Email *
Date of Birth *
Height (cm) *
Occupationsittingstandingphysically demanding
I DO NOT HAVE ANY medical conditions, allergies, etc.
Cardiac InsufficiencyJoint PainKidney ComplaintsAsthmaThyroid HyperfunctionThyroid HypofunctionVertigo / DizzinessSkin disordersMigraineDiabetesHigh Blood PressureGluten intolerance / AllergyLactose intoleranceLong CovidOther, e.g. Sleep Disturbance, Depression, Digestive Issues:
I AM NOT CURRENTLY TAKING ANY medication, hormones, etc.
Blood lipidsUric acidDiabetesThyroidAntipsychoticsDiureticsOther, e.g. Contraceptive / Hormone replacement:
I eat EVERYTHING (no food allergies?)
(Select 4 max)
I RARELY eat: MeatPoultryFishCheese
I NEVER eat: MeatPoultryFishCheeseCow’s MilkNatural YoghurtGoat’s Milk/YoghurtSheep’s Milk/YoghurtSeafoodSoya ProductsPorkOther:
Weight (kg) *
Desired Weight (kg) *
Package
(How do our packages differ?)
PREMIUM
STANDARD
Weight loss
min 15 kg
0-14 kg
Appointments
5 on-site or via video
3 on-site or via video
Support
email / phone
Support duration:
9 mths.
6 mths.
Price (CHF)
1'199.00
799.00
PREMIUMSTANDARD
Appointments via videoon-site
Appointments phone kick-off call
Where? ZurichLucerneBenglen (Fällanden)
Single Person or Group? Single PersonGroup of 2Group of 3
First name, last name of 2nd group member
First name, last name of 2nd group member First name, last name of 3nd group member
Price:
CHF 599.00
CHF 799.00
CHF 1'199.00
CHF 539.00
CHF 719.00
CHF 1'079.00
CHF 509.00
CHF 679.00
CHF 1'019.00
(prepayment)
(invoice)
Language nutrition planEnglishGermanFrenchItalian
Anything else you'd like to share?
I accept the GTC.
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