To begin treatment, you must fill out the Health Questionaire. Please fill in all of the required areas in blue text. No order can be filled without the completion of this Health Questionaire. You must be at least 18 years of age to begin treatment. Always consult with your doctor before taking any new treatment. If you have any questions, please call us at: 1-800-511-5706 Monday thru Friday from: 9am to 4pm EST.
*Please choose your treatment and quantity below: Quantity:
*Do you require a Prescription/Waiver?:
(Free Service with Purchase-if needed)
*First Name: *Last Name: *Date of Birth:
*Zip Code *Mobile/Home Telephone
**Important: Please fill in a valid e-mail address. Please verify spelling.
If we need to contact you. Which is your preferred method?:
Please describe what your ultimate weight should be? When do you plan to meet your weight loss goal?
What is your present weight?
What is your present height?
What was your highest weight in the past 3 years?
What was your lowest weight in the past 3 years?
What weight loss programs have you tried? How long did you try them?
How often do you exercise? (check one):
Are there other individuals in your immediate family that are over weight? (check one):
How would you describe your general stress level?(check one):
How many hours of sleep do you get per night?(check one):
Abdominal pain, Nausea/vomiting, Constipation, Diarrhea, Colitis, Diverticulitis, Hiatal hernia/reflux disease, Irritable bowel syndrome, Ulcers, Pancreatitis, Rectal Bleeding/rectal pain, Change in bowel habits, Hemorrhoids, Uterine problems, Ovarian problems, Infertility, Bleeding between periods, Wheezing, Shortness of breath, Productive or bloody cough, Asthma, Emphysema/COPD, Bronchitis, Pneumonia, Sleep apnea, Pulmonary embolism, Chest pain (Angina),
Palpitations/heart racing, Congestive heart failure, Heart attack, High blood pressure, Pacemaker, Heart valve, Rheumatic fever, Swollen glands, Anemia, Cirrhosis, DVT/phlebitis/blood clots, Jaundice, Lupus, Bleeding disorders,
Scleroderma, Kidney problems/stones, Bladder infections, Kidney failure, Hernia, Numbness/tingling, Loss of strength, Stroke (CVA/TIA), Headaches, Seizures/epilepsy, Multiple Sclerosis, Ear problems, Eye problems Nose/sinus problems.Throat problems, AIDS/HIV, Hepatitis A/B/C, Sexually transmitted disease, Tuberculosi, Nervousness,
Anxiety, Depression, Cancer of any type.
Please carefully review all of the health problems listed below. Do you have any of these medical problems?
If yes, please descibe below:
Have you had any other medical problems not listed here?
If yes, please descibe below:
Where will your products be shipped? Please fill in your complete address. Please double check your address for any mistakes before you submit. If you live in an apartment, please include your unit #. We are not responsible if you do not put in your correct address.
Is your shipping address the same as your billing address? (Your billing address is where your credit card statements are mailed to).
If it`s not the same, please fill in your billing address below:
I hereby certify that the above information given is true and correct.
I hereby certify that I am at least 18 years of age.
*Please read and agree to our Terms of Service. Check the boxes below and submit questionaire:
These products are not intended to diagnose, cure, or prevent any disease. These statements have not been evaluated by the Food and Drug Administration. Consult with a physician prior to use. Must be 18 years of age.
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*If your Health Questionnaire is accepted, then you can make payment for the products you wish to purchase. A customer representative will contact you by e-mail after they review your health questionnaire. Most questionaires are accepted & approved (97%) within the day of submission. We have 2 options for payment. Please choose your payment method.
We implement the highest standards and state of the art security measures to keep your electronic check information and transactions safe and secure. We use banking standard 256-bit encryption. If you ever have questions or concerns, please call our center at: 1-800-511-5706, Monday-Friday 9am to 4pm est.
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