CSN Online Order Form
CHRISTO STRYDOM NUTRITION INTRODUCED BY: BAINS LODGES INTERNATIONAL (PTY) LTD
Email address *
This form is for ordering purposes only. For general inquiries/quotes please visit the link below.
Are you a *
Name and Surname *
Your answer
ID number *
Your answer
Cellphone Number *
Your answer
Physical Address (No deliveries to farm/plot addresses) *
Your answer
Postal Code *
Your answer
Your nearest Postnet from which you will be able to collect:
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Marital status and Occupation
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I will collect my own order from:
Health Status *
Required
Prescribed medication for the health condition mentioned above
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Any know allergies *
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Gender
Current Weight, Goal Weight and Height
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Have you undergone any surgery that we should know of and when? *
Your answer
ANY OTHER INFORMATION WHICH MAY BE RELEVANT TO THE SUCCESSFUL PARTICIPATION IN THE CSN PROGRAM? *
Your answer
BE KIND AND HELP US OUT: What do you google when searching for a weight loss solution?
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Where did you hear about us?
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I DECLARE THAT ALL OF THE ABOVE MENTIONED INFORMATION IS CORRECT *
INDEMNITY I acknowledge that I have been warned that participation in the Christo Strydom Nutrition Program (CSN Program) might present potential serious health hazards. I declare that I voluntarily elected to participate in the above mentioned program despite the potential risks involved and that such participation is undertaken entirely at my own risk. I accept that none of Christo Strydom in his personal capacity, or in his capacity as the authorized representative of any of the entities involved in this program or their employees, or representatives, shall become legally liable for any damages resulting from my participation in the Christo Strydom Nutrition Program. I further accept that this indemnity will also be applicable in the event of participation in activities arranged and/or provided by any of the entities mentioned in the above mentioned agreement and/or Christo Strydom in his personal capacity. I further acknowledge that this agreement will also apply to any third party employed by Christo Strydom in his personal capacity or in his capacity as the authorized representative of any entity mentioned in this agreement, medical staff and practitioners included. I hereby discharge Christo Strydom in his personal capacity and the above mentioned entities, medical staff and practitioners from all claims, personal or otherwise, emanating from loss or damages suffered by me during my participation in the Christo Strydom Nutrition Program. *
PART 2: Please take note
SELECT THE CSN PACKAGE BEST SUITED FOR YOU. (For more info regarding the packages email: karien@kariencsn.co.za)
FOR INDIVIDUAL CSN PRODUCT ORDERS eg: 1 x AloeMag. 2 x Barley Grass Capsules etc.
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Thank you for you support and we wish you all the best on your CSN WEIGHT LOSS JOURNEY. Please visit my website www.kariencsn.co.za for CSN-Recipes and join our Facebook Page: CSN Diet Support Group for interactive support and motivation. For any other inquiries send us an email to karien@kariencsn.co.za
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