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Personal Profile

PERSONAL INFORMATION

First name

Last name

Phone

Birthday

Year

Month

Day

Height

Weight

Goal Weight

Waist Measurement

Hips Measurement

Upper Thigh Measurement

Do you take any medications and/or have any medical conditions?

Are you on hormones or birth control?

Are you taking any supplements?

Have you had any surgeries that would impact your health? (ie., Gallbladder Removal, etc)

Do you have any allergies or sensitivities?

What are you hoping to accomplish with this program?

Do you have anything else you'd like to share?

DECLARATION OF CONSENT AND PRIVACY

Consent to the Processing of Personal Data Including Health Data

Consent to the Processing of Personal Data Including Health Data:

I consent to the collection and processing of personal data relating to me — including information about my health, nutrition, and blood values —for the purpose of creating a personalized nutrition plan, participating in the Metabolic Balance nutrition program, and for the implementation and documentation of the agreed contractual services. The specific details of how my data will be processed, including who may receive it, are described in the data protection notice. I understand that this may

Consent to the Analysis of Pseudonymized Data

Consent to the Analysis of Pseudonymized Data:

I consent to the use of the data collected from me in the course of my participation in the Metabolic Balance nutrition program, including health-related data, in pseudonymized form by Metabolic Balance Global AG for internal analysis, program development, and scientific research. Pseudonymization is carried out in such a way that no direct conclusions can be drawn about my identity without the use of additional information. The data will not be combined with other data sets or used for marketin

Consent to the Contact and Personalized Offers

Consent to the Contact and Personalized Offers:

I would like to receive periodic newsletters from Metabolic Balance and its local distribution partners by E-Mail. These newsletters contain information about the Metabolic Balance nutrition program, the company itself, and the services and products offered by Metabolic Balance, as well as updates, devices, and applications in the health sector. By giving this consent, I also agree to newsletter tracking to help personalize future mailings and offers for me. I consent to this data processing and

The data controllers for the processing of your personal data within the framework of the Metabolic Balance® nutrition program are Metabolic Balance Global AG, MarleneDietrich-Allee 14, D-14482 Potsdam, Germany, BN Balance Inc 51 Marianne Dorn Trail, N2R 0H4 Kitchener, Canada, acting as joint controllers pursuant to Art. 26 GDPR. The processing of your data is based on your consent in accordance with Art. 6 para. 1 lit. a and Art. 9 para. 2 lit. a GDPR for the purposes of creating your personalized nutrition plan, providing individual coaching, conducting scientific evaluations, and – if you have subscribed – sending the health newsletter. You may withdraw your consent at any time with future effect. Upon withdrawal or extended inactivity, your data will be deleted or anonymized, unless legal retention obligations prevent this. In the course of providing services, data processors may be engaged. An up-to-date list and further details can be found in the full privacy notice at: www.mb-global.net/client-privacy-notice . You have the right to access, rectify, erase, restrict, or object to the processing of your data, as well as the right to data portability (Art. 15–21 GDPR), and the right to lodge a complaint with a data protection supervisory authority (e.g. the LfDI Brandenburg, Stahnsdorfer Damm 77, D-14532 Kleinmachnow, Germany). For questions regarding data protection, you may contact our data protection officer at: dp@metabolic-balance.com.

Your Signature

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