Health Survey

FREE Dinner booking:

FREE BOOKING DINNER INFO

Please fill up the necessary information below. We will simply use these information to
pre-qualify you for a special FREE DINNER for you and your guests at your home. We will also
share with you our secret healthy recipes at home and you will have a chance to win $100 to
$395 worth of gifts by allowing us to visit you at your home Please fill in the blanks and click on
the best answer you can give for the multiple choice questions. The information you will
provide us will remain confidential with us and will not be shared nor sold.

*Required Field

*First Name:

*Last Name:

*Street Address:

*City:

*State:

*Zip Code:

*Email

*Home Phone:

*Your Occupation:

Spouse:

Spouse's Occupation:

*Which of the following best describes your home?

Neither

Owned

Rented

List any foods that you are
allergic to or cannot eat.

When you shop or travel,
which do you use?

Mastercard

Visa

No Credit card

What type of cookware(s) do you
currently use?

Cast iron

Aluminum

Non-stick

Glass/enamel

Stainless Steel

Please enter the preferred date you
would like to have your FREE dinner:

Please enter the time of this dinner:

Please enter an alternative date for
the dinner:

Note: We will first coordinate with our chefs if they would be available on
your suggested dates, otherwise, we will keep in touch with you to confirm.