HCG Medical Form


Your Confidential HCG Medical Form


Please, Fill Out You HCG Medical Information Below



In order to proceed, we need your medical details on file OR a copy of your prescription from a licensed physician (you can Fax/E-mail it with this order form). If you do not currently have a prescription for the items ordered then we will have our physician review your order based on your medical profile below. Then proceed to ordering your HCG diet supplements.


My HCG Medical Profile

Please note that all fields followed by an asterisk must be filled in.
Male
Female
Feet
Inches
Meters
Centimeters
Stones
Kg
Pounds
High
Low
Normal
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes

Please enter the word that you see below.

  



By placing this order, I Have Read, Understood and Agree to the Terms and Conditions, Shipping Policy and Privacy Policy of hcgweightlossdiets.com. Now, proceed to ordering your HCG diet supplements.



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