To ensure you’re eligible to use our weight loss product safely, we just need a little more information. Please fill out the quick health questionnaire below. This will help us verify that the product is a great fit for you, so you can get the best possible results.

Health And Wellness Questionnaire

Your privacy is important to us, and all information will be kept confidential.

Personal Information

Enter your full name as per official records

Your Full Name

Provide a valid email for communication and updates.

Enter your phone number for follow-up and support.

Phone

Write your date of birth for age-related calculations.

Date of Birth (DD/MM/YYYY)

Provide your address for correspondence and delivery.

Address

Continue

Health And Wellness Questionnaire

Your privacy is important to us, and all information will be kept confidential.

Medical Info

Previous Step

Input your current weight for accurate assessment.

Your current weight (lb)

Specify your target weight to help track progress.

Your target weight (lb)

List any allergies you have to ensure safe and appropriate recommendations. Leave empty if none

Allergies eg: Peanuts,Shell fish (Leave empty if none)

List all medications you are currently taking. Leave empty if none

Current Medications (Leave empty if none)

Describe any medical conditions to tailor advice. Leave empty if none.

Current Medical Conditions (Leave empty if none)

Continue

Health And Wellness Questionnaire

Your privacy is important to us, and all information will be kept confidential.

Medical Conditions

Previous Step

Any history of thyroid problems?

(If yes please specify the condition)

Any history of pancreas problems?

(If yes please specify the condition)

Any history of Type 1 Diabetes?

(If yes please specify the condition)

Are you pregnant or planning to be?

Are you taking oral birth control?

By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may affect my eligibility to use this product safely. I acknowledge that this questionnaire does not replace professional medical advice, and I should consult with a healthcare provider if I have any concerns regarding my health or the use of this product.

Confirm Eligibilty

To ensure you’re eligible to use our weight loss product safely, we just need a little more information. Please fill out the quick health questionnaire below. This will help us verify that the product is a great fit for you, so you can get the best possible results.

Health And Wellness Questionnaire

Health And Wellness Questionnaire

Health And Wellness Questionnaire

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