Date of Birth
Why do you want to do hCG diet?
How did you discover merwin Rx-Compounding?
Do you experience?
High Blood Pressure
Low Blood Pressure
Please list other medical conditions:
Please list your current healthcare provider(s):
Address (include city, state, zip)
What do you know about hCG?
Have you tried losing weight with:
What has been successful?
What has been challenging?
How much do you currently weigh?
What is your goal weight?
What is your height?
What is your bone structure?
HCG Intake Form
Are you a vegetarian or vegan?
Please list any dietary restrictions:
What date do you plan on starting the hCG protocol?
Would you like to receive emails regarding merwin's upcoming events/promotions? We do not share your information.