Medical Questionnaire

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Medical Questionnaire

Start Your Medical Questionnaire

You must complete the following medical questionnaire for a physician to evaluate your medical history. Your order will not be considered until you complete this short form. Please allow one to two business days to process your order. An email notification will be sent showing order status.
MEDICAL QUESTIONNAIRE

This form is required and provides information to our physician for prescription.
Name*
First Last
Date of Birth
Month
Day
Year
Sex*
- Male
- Female
Height
(feet, inches) ex: 5', 4"
Weight*
Have you ordered from us before?*
Have you taken HCG for weight loss before?*
Have you taken Semaglutide/Tirzepatide before?*
Please upload a photo of the front of your ID to verify your identity.
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
Are you currently pregnant?*
Do you have a history of cancer?*
Are you currently under the care of a physician for a medical condition?*
Do you have any allergies or hypersensitivities to medication, vitamins or supplements?*
If so, please detail allergies or hypersensitivities
Are you currently taking medications or hormones?*
Please let us know who referred you (First & Last Name) or how you heard about us*
Terms And Conditions*
Agree
As with any weight loss program, there are no guarantees for individual weight loss. Information provided herein is based on historical research, studies, and successful results from the many thousands of former weight loss clients. Individual success is dependent upon a variety of factors such as following the diet protocol.

For this reason, all sales are final and there are no money back guarantees. We cannot accept returns even if the products are unopened — due to the concern of our citizens and dangers regarding medicine tampering, we have chosen to err on the side of caution by not re-selling products that have been delivered to someone’s home/business.

Biggest Sale! Save 20% Off All Kits! Promo code: 20%disc. We ship to all 50 states, Internationally, and to Canada.

Medical Questionnaire

Start Your Medical Questionnaire

MEDICAL QUESTIONNAIRE