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Food Order Form for Weight Sense at Derry Medical Center

Weight Sense invites you to place your foods order using this page. You should be able to pick up your order upon arrival to your next session.

*Indicates required field

 
 

Date:

 

*First Name:


 

*Last Name:


 

*Email Address:


 

*Phone Number :


 

*Please indicate your class day & time, OR if outside product sale:

 

 


  Questions / Comments:

 
Products Offered: Price: Qty: Subtotal
Shakes      
  HMR 500 Chocolate $36.50/box
  HMR 500 Vanilla $36.50/box
  HMR 500 Chicken Soup $36.50/box
  HMR 70 Plus Chocolate $38.50/box
  HMR 70 Plus Vanilla $38.50 /box
  HMR 800 Chocolate $38.50/box
  HMR 800 Vanilla $38.50/box
  HMR 120 Chocolate $21.50/can
  HMR 120 Vanilla $21.50/can
Entrees - Per Meal      
  5 Bean Casserole $3.50
  Chicken w/BBQ Sauce $3.50
  Mushroom Risotto $3.50
  Beef & Bean Enchilada $3.50
  Vegetable Stew w/Beef $3.50
  Chicken Creole $3.50
  Chicken Parm $3.50
  Lasagna $3.50
  Savory Chicken $3.50
  Turkey Chili $3.50
  Cheese Ravioli $3.50
  Beef Strogonoff with Noodles $3.50
  Pot Roast with Vegatables $3.50
  Pasta Fagioli $3.50
Bars - Single Serving Size    
  Peanut Butter $1.25
  Honey Yogurt $1.25
  Chocolate $1.25
  Blueberry $1.25
Hot Cereal      
  Multigrain $38.50/box
    Total 

 

Please double-check your quantities before submitting this form, to be sure you're ordering the amounts you need. We will fill your order promptly and have it available to you by your next session. Thank You.


  

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