Slimming Club Application Form
Please answer all questions as fully as possible. Rest assured that all information provided will be treated in the strictest of confidence. Classes are WOMEN ONLY, unless otherwise stated.
Locations, Days & Times Of Classes Available (please choose):
BIRCHGROVE Tuesday's at 7pm
BIRCHGROVE Wednesday's at 12.30pm
Bynea, Llanelli Wednesdays at 6.30pm
Gower College Wednesdays at 12.00pm
Date Of Birth (dd/mm/yy)
Mobile Phone Number
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
What is your goal? (e.g. to lose 2 stone, have more energy and sleep better)
Why are you joining? (please dont say to lose weight, say WHY you want to lose the weight, what will it do for you etc :-))
Have you ever suffered from an eating disorder?
Are you currently receiving any medical treatment or taking any medication?
If yes please give full details in the box below.
Slimming Club - Medication Policy
It is the responsibility of each member to ensure that there are no medical reasons why they should not start slimming. If in any doubt, members should check with their GP.
In essence our plan is simple healthy home cooked food. We don’t include anything that’s not natural. But that’s said if you take medication sometimes they can have interactions with food.
It’s your responsibility to check with your GP of Pharmacist for any food and drug interactions.
• Thyroxine/Antithyroid Drugs (loads of foods)
• Waffarin (green leafy veg, broccoli, sprouts, asparagus)
• Digoxin (fiber such as wheat bran not around meal times)
• Statins (grapefruit)
• Calcium Channel Blockers (grapefruit)
• Antidepressants (red wine, beer, smoked fish, aged cheeses, and dried fruits)
• Grapefruit Juice
• Leafy Green Vegetables
• Natural Black Liquorice
• Matured Cheese
• Smoked or Aged Meats
• Alcohol (insulin)
You don’t always need to avoid these foods but need to keep a consistent daily intake, discuss this with your pharmacist or GP.
Good advice is, when you get a new prescription always read the drug warning labels and ask your GP or pharmacist about which foods, or other drugs you should be concerned about taking at the same time.
We always recommend members follow the medical and any dietary advice they have been given by their doctor or other health professional.
Our slimming club's are not intended as a substitute for any advice or treatment prescribed by a doctor.
If you've had or if you are concerned that you may currently have an eating disorder it is important to consult your doctor for advice.
People with serious health conditions like cancer, can usually benefit from a good nutritional programme. This can only be done in our slimming clubs with medical clearance and in conjunction with your doctors as there is always a risk that any weight changes you experience could be due to your illness rather than dietary adjustments.
We cannot accept pregnant women and members who become pregnant after joining are not allowed to participate in the weight loss element of our club but can carry on eating healthy and educating themselves. New mothers are welcome back 12 weeks after child birth.
If you are currently receiving any medical treatment or taking any medication, please give full details in the box below.
List all medication
If you take medication check box to say you have read, understand, and accept The Medication Policy (above)
Yes I have read, understand and accept the medication policy
How Did You Find Out About The Slimming Club?
1. Referral (if you were referred, write the name of the person who referred you)
4. Richards Website
5. Other (please enter in box below)
Do Not Fill This Out