HCG Order Form

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Patient Name

First

Last

DOB

Patient Phone Number

Patient Email Address

Are you a new patient?

Have you taken HCG in the past? *

When was the last time you took HCG?

What is Your Current Weight?

What is Your Height? (feet, inches)

What type of exercises are you doing? *

How many calories do you eat daily? *

Have you started any new supplements or prescription medicines? If yes, list them below.

Check the box of any current supplements that you are taking? *

Women only: When was the first day of your Last Menstrual period? Type N/a if no cycles.

Do you want a 25 day or 40 day HCG supply? *

Do you want to add Phentermine with your HCG order? *

If you answered yes to adding phentermine, how much do you want to add?

HCG needs to be refrigerated and can deactivate with constant shaking, therefore, HCG has to be picked up in the office. *

Address if you want medicine shipped

and start Check

Additional Message (Optional)

Checklist to start HCG

Today's Date and Time of Request

Date

Time

Signature (type full name) *

Give us a call (555) 123 45678

Monday – Friday | 7am – 5pm PST

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