MHA Nation Monthly Fee Agreement

Name*

First Last

Mailing Address*

Street Address City State

ZIP Code*

Registration Number*

Email*

Phone*

It looks like you're within 30 miles of our Mt. Zion location! We do make some special exceptions, but please contact us to see if you qualify for our online program. Otherwise, we encourage you to visit our Physician's Choice Wellness (PCW) website to learn more about our in-house program.

It looks like you're within 30 miles of our Forsyth location! We do make some special exceptions, but please contact us to see if you qualify for our online program. Otherwise, we encourage you to visit our Physician's Choice Wellness (PCW) website to learn more about our in-house program.

It looks like you're within 30 miles of our Effingham location! We do make some special exceptions, but please contact us to see if you qualify for our online program. Otherwise, we encourage you to visit our Physician's Choice Wellness (PCW) website to learn more about our in-house program.

It looks like you're within 30 miles of our Taylorville location! We do make some special exceptions, but please contact us to see if you qualify for our online program. Otherwise, we encourage you to visit our Physician's Choice Wellness (PCW) website to learn more about our in-house program.

It looks like you're within 30 miles of our Vandalia location! We do make some special exceptions, but please contact us to see if you qualify for our online program. Otherwise, we encourage you to visit our Physician's Choice Wellness (PCW) website to learn more about our in-house program.

My goal is to:*

Lose weight and keep it off
Maintain my current weight

Medication*

I am not on any type of medication that would require a doctor to monitor my weight loss to determine any adjustments necessary.
I am on medications to control health conditions related to my weight. I will continue to see or consult my physician for all medical needs or adjustments.

Program Costs

Once completing this form and submitting payment, you will be contacted within 48-hours by a Lifestyle Coach from Journey to Health to set up shipping, email, and basic information.

We ship product on Wednesdays, Thursdays, and Fridays. There is no shipping on weekends, Mondays, or Tuesdays.

Your credit/debit card on file will be charged a monthly fee. If we do not receive proper payment, you will not be allowed to order any meal replacements.

I understand the following to be costs associated with the Journey to Health Program:*

$29 Basic Monthly Package - Weekly email with lifestyle modification material and a question & answer form to be emailed back. Credit/Debit card will be charged upon completion of this form
Meal Replacements as Recommended by Nutritionist - $100 for 2-week bundle or $200 for 4-week bundle (plus shipping). Purchased at our Online Store. Packages will be shipped to you.

Program Compliance

Program Compliance Agreement*

I have read, understand, and agree to the following statements and it is my wish to participate in the Journey to Health Program.

I understand that in order to fully use the tools provided to me, I must continue to self-report my weight and nutrition as recommended by the Journey to Health team.
I realize that I have the option of leaving the program at any time but I must notify the center in writing thirty days prior.
I understand that if I have a Facebook account, I agree to be added to the private Facebook group for support and accountability. If I leave the program, I will be removed from that page. Journey to Health will monitor the Facebook group.
I understand that I will be added to the Journey to Health Email List in order to be emailed information pertaining to my program participation as well as any special notice. Journey to Health does not share email or personal information with third parties.
I understand that any meal replacements I purchase will only be shipped to me and I will not be able to pick them up from a free-standing Journey to Health clinic. I will consume these products only under the advice of Journey to Health.
I understand that by submitting this form I am in effect signing and agreeing to all terms listed above.

Website Privacy Consent*

I consent to having Physician's Choice Wellness and this website store my submitted information so they can register me for the PCW Weight Loss Program. I understand that my information will be kept private and not shared with third parties.

Journey to Health Monthly Fee*

Price: $29.00

Your credit card will be charged automatically each month for your Journey to Health Program. You may cancel anytime with 30 days' notice.

Credit Card*

American Express

Discover

MasterCard

Visa

Total

$0.00

MHA Nation Online Healthy Weight Loss Registration Form

Program Costs

Program Compliance