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.

Gender:*
Gender:*

	Male
	Female

Date of Birth (day/month/year): *
Date of Birth (day/month/year): *

What is your height?

	Feet
	Inches
	Meters
	Centimeters

Enter data (Ft/In or m/cm.):*
Enter data (Ft/In or m/cm.):*

What is your weight?

	Stones
	Kg
	Pounds

Enter data:*
Enter data:*

How is your blood pressure?*
How is your blood pressure?*

	High
	Low
	Normal

Do you smoke?*
Do you smoke?*

	Yes
	No

Do you drink?*
Do you drink?*

	Yes
	No

Are you pregnant, breast-feeding, or trying to get pregnant?*
Are you pregnant, breast-feeding, or trying to get pregnant?*

	Yes
	No

Do you suffer from any allergies?*
Do you suffer from any allergies?*

	Yes
	No

If yes, Please detail...

Why are you buying the HCG for? *
Why are you buying the HCG for? *

Are you currently taking any other medication?*
Are you currently taking any other medication?*

	Yes
	No

If yes, Please detail...

Is there a history of any disorder/s that has run within your family such as heart problems, etc?*
Is there a history of any disorder/s that has run within your family such as heart problems, etc?*

	Yes
	No

If yes, Please detail...

Have you ever had any surgery (operations)?*
Have you ever had any surgery (operations)?*

	Yes
	No

If yes, Please detail...

Can you think of any other health / medical details not mentioned above?*
Can you think of any other health / medical details not mentioned above?*

	Yes
	No

If yes, Please detail...

Signature:*
Signature:*

Initials*
Initials*

Date (Day/Month/Year): *
Date (Day/Month/Year): *

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Please, confirm E-mail Address (Compare! No typos)*
Please, confirm E-mail Address (Compare! No typos)*

Please, white list this email: [hcgdietadvisor@hcgweightlossdiets.com] Verify it doesn't get into Spam*
Please, white list this email: [hcgdietadvisor@hcgweightlossdiets.com] Verify it doesn't get into Spam*

Yes

Full Address*
Full Address*

Telephone Home*
Telephone Home*

Telephone Mobile*
Telephone Mobile*

Country*
Country*

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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