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.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
My HCG Medical Profile
Please note that all fields followed by an asterisk must be filled in.
Gender:*	Male Female
Date of Birth (day/month/year): *
What is your height?	Feet Inches Meters Centimeters
Enter data (Ft/In or m/cm.):*
What is your weight?	Stones Kg Pounds
Enter data:*
How is your blood pressure?*	High Low Normal
Do you smoke?*	Yes No
Do you drink?*	Yes No
Are you pregnant, breast-feeding, or trying to get pregnant?*
Yes No
Do you suffer from any allergies?*
Yes No
If yes, Please detail...
Why are you buying the HCG for? *
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?*
Yes No
If yes, Please detail...
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?*
Yes No
If yes, Please detail...
Signature:*
Initials*
Date (Day/Month/Year): *
First Name*
Last Name*
E-Mail Address*
Please, confirm E-mail Address (Compare! No typos)*
Please, white list this email: [hcgdietadvisor@hcgweightlossdiets.com] Verify it doesn't get into Spam*
Yes
Full Address*
Telephone Home*
Telephone Mobile*
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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