Application for Cohen’s Weight Loss Program

Gall bladder *

No

Yes

Heart condition *

No

Yes

Chronic constipation *

No

Yes

High blood pressure *

No

Yes

Hysterectomy *

No

Yes

High cholesterol *

No

Yes

Liver *

No

Yes

Diabetes *

No

Yes

Kidney *

No

Yes

Thyroid *

No

Yes

Stroke *

No

Yes

Depression *

No

Yes

Physical impairment, other operations or conditions *

No

Yes

Food allergies or restrictions *

No

Yes

Currently prescribed medications *

No

Yes

Have you had any major surgery in the past 6 - 8 weeks? *

No

Yes

Are you pregnant? *

No

Yes

Are you breast feeding? *

No

Yes

Are you a vegetarian? *

No

Yes

If you are not a vegetarian, would you like tofu as a meal option?

No

Yes

If you are a vegetarian, please select at least 5 of the following proteins:

Cheese

Eggs

Yoghurt

Tofu

Seafood

Poultry

How did you become aware of the Cohen's Weight Loss program?

Below are the terms and conditions for registering. By registering, you are agreeing to have read and accept these terms.

The dietary advice and suggested eating program provided to me by Cohen's Weight Loss Clinic are recommended by Dr Rami Cohen who is a registered medical practitioner in South Africa and whose head office is located in the United States of America.

The personal information I have supplied on the Application Form is true and complete, and is critical to the advice I will receive through Cohen's Weight Loss Clinic. Neither Dr Cohen nor Cohen's Lifestyle Clinic Pty Ltd nor any Cohen's Weight Loss Clinic outlet will be liable for any adverse health conditions that arise from the provision of false or incomplete information. Precautions are taken wherever possible to prevent personal information from becoming available to unauthorised persons or organizations. Under no circumstances will client information be provided to, sold or otherwise disseminated to external mail lists of any description. Credit card details collected for the purposes of payment are destroyed after being processed.

I hereby grant permission for my blood test results and the information supplied on this application form to be made available to Dr Cohen and to Cohen's Lifestyle Clinic Pty Ltd for the compilation of my personal Eating Program and for future reference.

Although the success of this program is proven, people are different in their metabolism and some might experience weight loss which is slower than the average mentioned on the website.  Therefore, Cohen's Weight Loss Clinic gives no warranty regarding weight loss or improvement in health from the suggested dietary advice or eating program given to me.

Dr Cohen recommends that I consult my doctor before starting any diet or changing my eating habits.

I understand that I may need to slow down any type of sporting activity or extensive physical effort I usually conduct, during the time I am on my program.

I understand that my contract support time is 12 (twelve) weeks only. Further support and the cost thereof will be at the discretion of the clinic. I understand that I must start my program 3 (three) days after the date is was emailed to me and the contract period starts from the start date of my program.

As my program will be created based on the medical information and blood test results I have supplied, I will not share my program with anyone because I understand that my program will not have the same results and may be harmful to their health. In any event, Dr Cohen and Cohen's Lifestyle Clinic Pty Ltd have copyright of my program and all associated material and I acknowledge that I may not make (or allow the making) of any copy of my program or associated material and that I may not make my program or related material available for the use of any other person.

The "cooling off period" expires once I have had my initial blood test, after which no refunds can be made. Should Dr Cohen decide, after examination of my medical history and/or my blood test results, that I cannot go on his program, I will be given a full refund, excluding the cost of the initial blood test.

I undertake to follow my Eating Program 100% and to have the required repeat blood tests on the due dates. I understand that without these blood test results Dr Cohen cannot create my personalised Refeeding Program, and my support contract expires at this point. I further understand that my personalised Refeeding Program cannot be created until I am within 2 kgs of my ideal weight range set by Dr Cohen and within support contract time.

I undertake to notify the clinic of any change in medical information/conditions/medications/pregnancy as soon as possible. I understand that these changes may result in my no longer being suitable to continue on the program, which will not entitle me to a refund.

I have read and accept the terms listed above. (Ticking this box will enable the submit button)

Cohen’s Weight Loss Program Application