Medical Questionnaire

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Medical Questionnaire

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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 business day to approve and 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?*
If you have a prescription already, please upload a copy
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
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, supplements or hormones?*
Please let us know who referred you (First & Last Name) or how you heard about us
Additional Comments
FDA Disclaimer*
Agree
The FDA has not approved HCG for weight loss; itʼs use for weight loss is considered an “off label” application. The use of HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or “normal” distribution of fat, or that it decreases the hunger and discomfort associated with calorie restricted diets.
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 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 supplement product 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.

Welcome to Weightloss Express! We are here to help you reach your weight loss goals! Please email us at support@buyhcgkits.com to ensure we received your message.

Medical Questionnaire

Start Your Medical Questionnaire

MEDICAL QUESTIONNAIRE