High Five Health, Inc.

Interested in losing weight and getting healthy? Do you have high blood pressure or cholesterol? Are you diabetic? Are you interested in finally leading the healthy life you've always wanted? For more about this program - please click here. If you are interested in becoming a client, please complete the form below. We will be contacting you as soon as possible. If you have questions about the program prior to being contacted, please feel free to call Bill at (407) 619-5005 or Kate at (407) 619-5006.

 

To place your order or login, please click here

 

First Name:

Last Name:

Email Address (required):

Phone:

I prefer to be contacted by:

email     phone

Your Height:

 

Your Current Weight:

Your Goal Weight:

Your level of exercise:

Age:

Birthday:

   

Sex:

male   female

Are you currently taking any medication:

yes     no

Do you have any allergies:

yes     no

Have you been diagnosed with Diabetes:

yes     no

Do you have high blood pressure:

yes     no

Do you have high cholesterol:

yes     no

Do you have other health related conditions:

yes     no

Have you tried other weight-loss programs:

yes     no

What is your #1 reason
for wanting to lose weight:

On a scale of 1-10, how motivated are you:

 (be honest)

Are there friends or family that would like to start with you:

yes     no

How did you discover High Five Health. Inc.:

Were you referred by someone,
if so, please tell us who
(they will receive a referral credit)

yes     no
if so, who:

Comments:

 

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Lose weight with The Gernaats!

Bill Gernaat, Certified Health Coach | Bill@HighFiveHealth.com | (407) 619-5005 
Kate Gernaat, Certified Health Coach | Kate@HighFiveHealth.com | (407) 619-5006
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