Mediterranean and Macrobiotic Diet Fusion for Optimal and Enjoyable Nutrition

Please use this form to complete the intial sign-up information to begin receiving meals. Once you have submitted the information requested, we will contact you to collect billing information and setup your first delivery.

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Home Phone

Business Phone

Mobile Phone*
Mobile Phone*

Delivery Instructions (what to do once a driver has arrived at your address)*
Delivery Instructions (what to do once a driver has arrived at your address)*

Backup Delivery Instructions (what to do if the driver cannot complete the regular instructions)

Choose Your Program*
Choose Your Program*

	\\STANDARD PROGRAMS >>
	Family 12 Two-Serving Entrees (24 servs. / 4 servings of each entree) - $130/delivery
	Individual 6 Entrees (12 servs. 2 servings of each entree) - $70/delivery
	Less Cookin 3 Entrees (6 servs. / 2 servings of each entree) - $45/delivery
	NEW SINGLE SERVING ENTREES: Lifestyle 6 Entrees (6 servs. / 1 serving of each entree) - $55/delivery
	\\WEIGHT LOSS PROGRAMS >>
	Family Weight Loss 12 Entrees (24 servs. / 4 servings of each entree) - $140/delivery
	Individual Weight Loss 6 Entrees (12 servs.) - $80/delivery
	Less Cookin Weight Loss 3 Entrees (6 servs. / 2 servings of each entree) - $53/delivery
	NEW SINGLE SERVING ENTREES! Lifestyle Weight Loss 6 Entrees (6 servs. / 1 serving of each entree) - $65/delivery
	\\GLUTEN FREE PROGRAMS >>
	Family Gluten Free 6 Entrees (12 servs. / 4 servings of each entree) - $80/delivery
	Less Cookin Gluten Free 3 Entrees (6 servs. / 2 servings of each entree) - $65/delivery
	NEW SINGLE SERVING ENTREES! Lifestyle Gluten Free 3 Entrees (3 servs. / 1 serving of each entree) - $42/delivery

Delivery Days*
Delivery Days*

Tuesday

Make my order an A La Carte order (allows you to choose exactly which entrees you want to receive or request to avoid certain foods you dislike - add $10 to each delivery)?*
Make my order an A La Carte order (allows you to choose exactly which entrees you want to receive or request to avoid certain foods you dislike - add $10 to each delivery)?*

	No
	Yes

Add desserts to each of my deliveries - $5/ea (how many):

Add side miso soups to each of my deliveries - $3/ea (how many)?

Add side vegetable soups to each of my deliveries - $3/ea (how many)?

Add a large container of the chef's special side vegetables to each of my deliveries - $8/ea (how many)?

Add 1 serving entrees to each of my deliveries (how many)?

Add 2 serving entrees to each of my deliveries (how many)?

How did you hear about us?*
How did you hear about us?*

Comments:

I certify to have no serious allergies and understand that even with cautious food preparation practices that avoiding particular foods can never be assured and I promise to hold Macro-Mediterranean Holistic Nutriton, Ltd. and its partners harmless in the event ingredients I dislike or am allergic to were to be contained in the foods provided to me.*
I certify to have no serious allergies and understand that even with cautious food preparation practices that avoiding particular foods can never be assured and I promise to hold Macro-Mediterranean Holistic Nutriton, Ltd. and its partners harmless in the event ingredients I dislike or am allergic to were to be contained in the foods provided to me.*

I Certify To Have No Serious Allergies

I understand and agree to be charged a startup cooler and ice pack fee of $20.00 that will become non-refundable after my 4th delivery. I understand that if I decide to cancel before my 4th delivery it is my responsibility to return any delivery coolers and ice packs to Macro-Mediterranean Holistic Nutrition, Ltd. who upon receipt of the coolers in good condition will at its discretion return the $20.00 fee to me. I also understand that it is my responsibility to return delivered coolers and ice packs within 30 days of my receiving them and if I fail to do so I may be charged a penalty of $15.00 for each cooler and $5.00 for each set of ice packs in my posession. Finally I understand that at all times coolers and ice packs are and always remain the property of Macro-Mediterranean Holistic Nutrition, Ltd. and will treat them as such while they are in my posession and always return them in the same state as they were received.*
I understand and agree to be charged a startup cooler and ice pack fee of $20.00 that will become non-refundable after my 4th delivery. I understand that if I decide to cancel before my 4th delivery it is my responsibility to return any delivery coolers and ice packs to Macro-Mediterranean Holistic Nutrition, Ltd. who upon receipt of the coolers in good condition will at its discretion return the $20.00 fee to me. I also understand that it is my responsibility to return delivered coolers and ice packs within 30 days of my receiving them and if I fail to do so I may be charged a penalty of $15.00 for each cooler and $5.00 for each set of ice packs in my posession. Finally I understand that at all times coolers and ice packs are and always remain the property of Macro-Mediterranean Holistic Nutrition, Ltd. and will treat them as such while they are in my posession and always return them in the same state as they were received.*

I Understand and Agree.

Once your order has been submitted and we have talked to confirm your start date and collected billing information, you will be put on a weekly recurring billing cycle based on your requested program. Once this is setup, you may suspend a delivery or cancel future recurring payments and deliveries at any time by notifying us before 5 PM, 3 business days before your next delivery. Once this deadline has passed, orders become non-refundable since at that point recipes are scaled and ingredient orders are placed resulting in it becoming impossible to cancel the preparation of the food in an order despite notice of a cancellation.*
Once your order has been submitted and we have talked to confirm your start date and collected billing information, you will be put on a weekly recurring billing cycle based on your requested program. Once this is setup, you may suspend a delivery or cancel future recurring payments and deliveries at any time by notifying us before 5 PM, 3 business days before your next delivery. Once this deadline has passed, orders become non-refundable since at that point recipes are scaled and ingredient orders are placed resulting in it becoming impossible to cancel the preparation of the food in an order despite notice of a cancellation.*

I understand and agree to the recurring billing arrangement and terms.

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