Date
Name
Date of Birth
Why do you want to do hCG diet?
How did you discover merwin Rx-Compounding?
Health History
Do you experience?
High Blood Pressure
Low Blood Pressure
Thyroid Dysfunction
Diabetes
Hormone Imbalance
Please list other medical conditions:
Current Medications:
Please list your current healthcare provider(s):
Gallbladder Stones
Gout
Address (include city, state, zip)
Phone
Email
What do you know about hCG?
Diet History
Have you tried losing weight with:
South Beach
Paleo Diet
Weight Watchers
Jenny Craig
Mediterranean Diet
Nutrisystem
Atkins
Zone
Slim-Fast
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?
Small
Medium
Large
Unsure
HCG Intake Form
Are you a vegetarian or vegan?
Yes
No
Please list any dietary restrictions:
What date do you plan on starting the hCG protocol?
Other
Would you like to receive emails regarding merwin's upcoming events/promotions? We do not share your information.
Yes
No