Low Calorie Diet

You can submit this form to The Center for Medical Weight Loss of Santa Fe electronically so your meal products can be ready for your next visit. Please submit this form at least one business day before your visit to make sure we have time to complete your order.

Instructions: Please order 35 items from the list below, but no more than 7 from the bars/soups/crisps list. If you require additional products, please list them in the “Additional Information” box below. Be as complete as possible. Fields marked with * are required.

* Patient Name
* Planned Pickup Date	January February March April May June July August September October November December / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2017 2018  (at least one business day from now)
* Planned Pickup Time	1 2 3 4 5 6 7 8 9 10 11 12 : 00 15 30 45   AM PM  (hour : minute am / pm)
* Best Phone Number	(for questions about your order)
* Please Choose from the Following Selection of Products
Ready-to-Drink Shakes   Chocolate Berry Vanilla Total 0 Powder Shakes   Chocolate Berry Vanilla Total 0 Note: No more than one bar, soup or crisp per day Protein Bars   Caramel Peanut Chew Fudge Almond Coconut Chocolate Brownie Cinnamon Crunch Chocolate Graham Crunch Crispy Peanut Butter Totally Toffee Mixed Berry Total 0 Soups   Chicken Soup Tomato Soup Total 0 Crisps   BBQ Sour Cream & Onion Total 0
Total Products Ordered	0
Additional Information or Instructions
Please Note the Following	Please place orders at least 24 hours prior to planned pickup time Orders not picked up within 24 hours of indicated pickup time will be returned to inventory Please check your items before leaving our office to make sure your order is correct Unfortunately we cannot offer any exchanges or returns on these products
* Test Question	3 + 1 =   (this helps prevent spam)

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