I Wish to Join The PikLife Program

Please fill out the information below

 
  • Step 1 Complete the registration form below -please fill in all the fields
  • Step 2 A PikLife consultant will contact you to discuss your registration.
  • Step 3 You may receive via email a blood test request form please a Arrange to have your blood test as soon as you receive the request form
  • Step 4 Arrangements are being made to get your PikLife kit delivered to you
  • Step 5 Your PikLife consultant will contact you to discuss your program
  • Step 6 Begin your program once your kit arrives
  • Step 7 Once we receive your blood test results where ordered you may be sent an update to your program

 

CLIENT DETAILS
Date of Enrolment  
First Name Family Name
Address
Suburb City State
Country P/Code Telephone
Email (REQUIRED)
Sex   Date of Birth Age
Race Current Weight Height (cms)
Target Weight  
MEASUREMENTS Please use centimeters    
Bust / Chest
Thigh
Hips
Arm
Waist
Neck
    
   

CLINICAL HISTORY ( Please indicate if you have or have had any of the following)

High or Low Blood Pressure
Heart Condition
Asthma
Headaches / Migraine
Neck or Back Injury
Blackouts
Joint Pain
Digestive Upsets
Diabetes
Kidney Problems
Liver Disease
Cancer (any kind)
Recent Surgery

Please Detail

Any Other Known Medical Problem
Please List Current Medications

Dietary Preferences (Please indicate if the client eats the following foods)

RED MEAT
POULTRY
PORK
DAIRY
SEAFOOD
TOFU
EGGS

VEGITARIAN ONLY

 

A PikLife consultant will be contacting you shortly to discuss your registration and will make arrangements with you for payment for your program.