Are employed by Southcoast Health?* Yes No Program* Optifast Full Optifast Partial Maintenance Optifast Full Prescription 5/day 6/day 7/day 8/day Optifast Partial Prescription 1/day 2/day 3/day 4/day Maintenance Prescription 1/day 2/day 3/day Items to Order* Select All Ready To Drink (RTD) Powder (carton only) Bars (carton only) Soup (carton only) Chocolate RTD ShakePlease enter a number from 0 to 50.Vanilla RTD ShakePlease enter a number from 0 to 50.Stawberry RTD ShakePlease enter a number from 0 to 50.Chocolate Powder Shake MixPlease enter a number from 0 to 10.Please list the number of cartons of Chocolate Powder Shake Mix you would like to order.Vanilla Powder Shake MixPlease enter a number from 0 to 10.Please list the number of cartons of Vanilla Powder Shake Mix you would like to order.Strawberry Powder Shake MixPlease enter a number from 0 to 10.Please list the number of cartons of Strawberry Powder Shake Mix you would like to order.Meal Replacement Bar - ChocolatePlease enter a number from 0 to 10.Please list the number of cartons of Chocolate Meal Replacement Bars you would like to order.Meal Replacement Bar - Apple CinnamonPlease enter a number from 0 to 10.Please list the number of cartons of Apple Cinnamon Meal Replacement Bars you would like to order.Meal Replacement Bar - Peanut Butter / ChocolatePlease enter a number from 0 to 10.Please list the number of cartons of Peanut Butter / Chocolate Meal Replacement Bars you would like to order.Meal Replacement Bar - MixPlease enter a number from 0 to 10.Please list the number of cartons of Mixed Meal Replacement Bars you would like to order.Soup Mix - Chicken SoupPlease enter a number from 0 to 10.Please list the number of cartons of Chicken Soup Mix you would like to order.Soup Mix - Tomato SoupPlease enter a number from 0 to 10.Please list the number of cartons of Tomato Soup Mix you would like to order.Soup Mix - Vegetable SoupPlease enter a number from 0 to 10.Please list the number of cartons of Vegetable Soup Mix you would like to order.Pick Up Location Dartmouth Fall River Wareham Pickup Date* DD slash MM slash YYYY AgreementI authorize the Weight Management Programs at Southcoast Health charge my credit card for the monthly charges associate withe my program fees for the Weight Management Program. In order to cancel the recurring billing process, I am required to contact the Weight Management Program in writing 2 weeks in advance to either cancel the associated charge, or arrange for an alternative method of payment.Name* First Last Email* Date* MM slash DD slash YYYY CAPTCHA
