Personal Details

• Full Name: ____________________________________

• Date of Birth (MM/DD/YYYY): _____________________

• Phone Number: __________________________________

• Email Address: ___________________________________

Preferences

• Favorite Smoothie Flavor(s):
  ☐ Berry Blast
  ☐ Tropical Twist
  ☐ Green Energy
  ☐ Protein Power
  ☐ Other: _______________________

• Allergies or Dietary Restrictions:

  ---

• Preferred Contact Method:
  ☐ Email ☐ Text Message ☐ Phone Call

Loyalty Program (Optional)

• Would you like to join our loyalty rewards program?
  ☐ Yes ☐ No

• Receive updates, deals & freebies?
  ☐ Yes, sign me up!
  ☐ No, thanks.

Signature: __________________________ Date: ___________

Thank you for being part of the Mr. Smoothie family! 🍓