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Welcome to the JHS Weight Management Solutions On-Line enrolment form

In order to successfully register to receive your personal JHS Weight Loss Program, please complete our enrolment form. Please do not leave any section blank as this will only delay the delivery of your program.

You have 2 membership options to choose from

  1. Our self managed On-line package US$125-00 (AU$165-00  GBP £88-00).
  2. Our  Standard  program at US$450-00 (AU$599-00 GBP £320-00).
    You get  access 6 months access to our on-line members area where you will be able to update you statistics weekly and receive weekly progress reports, access our guided meditation programs, download our Back to Basics Recipe book and the book Better Body Better Health,  Plus you receive email support.

Once you have completed filling in the enrolment form you will be directed to the JHS terms and conditions page you will need to accept the terms and conditions before being redirected to the PayPal payment gateway. Once you have finalized your payment we will arrange to send you your program and website log in information.

Date of Submission: * DD/MM/YYYY

First Name (Given Name): *

Family Name: *

Email: *

Address: *

Suburb: *

City: *

State: *

Country: *

Post code: *

Telephone: *

Sex: *

Date of birth : * DD/MM/YYYY

Age: *

Race: *


Measurements

(IMPORTANT NOTE --- only enter the number value do not type in Kg, Cm, Inch or Lbs after the number eg 75 Kilo's would be entered as 75 NOT 75Kg - 38 Centimetres would be entered as 38 not 38cm )

Weight : *

Height: *

Target Weight: *

Units of Measure: *
(Metric: Kgs and Cms, Imperial: Lbs and Inches)

Chest: *

Thigh: *

Hips: *

Arm: *

Waist: *

Neck: *


Medical Conditions

BP
Heart
Asthma
Headache
Back/Neck
Blackout
Joint Pain
Digestive
Diabetes
Kidney
Liver
Cancer
Surgery

Other Medical Conditions:

Medications:


Food Preferences

Red meat
Game meat
White meat
Poultry
Fish
Shellfish
Dairy
Eggs
Tofu
Soy Protein
Vegetarian
Ovo Lacto
Vegan

Additional Information:


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