Confidential Self Evaluation & Informed Consent Form

    Welcome to the hCG Protocol for Weight Loss

Confidential Evaluation Form
Thank you for choosing HCG PROTOCOL to assist with reaching your fat loss goals. This form is to be completed by all new patients before your first consultation. It is important that you review and complete this information before your initial visit so we can be better prepared to start your lab work, exam and Stage 1 of your HCG Protocol Weight loss program. This will allow us to make better use of the time when we get together.

It is essential that this information is filled out completely. We will be reviewing all the information to create a personalised file for you, so please answer all questions honestly and to the best of your abilities. Please feel free to add any additional information to your responses that you feel will be beneficial for your first visit.

N/A if not applicable

DATE OF BIRTH

:
(NOTE: Due to the nature of the product, someone must be able to be attendance at the given address to receive the package on the day of delivery)
Please add delivery address (where someone will be in attendance to accept on day of delivery):

MEDICAL STATUS

Which best describes you?

Weight loss goal

Type Date  
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Please check all that apply to you

Medication Name Strength (Milligrams) Dose (How often per Day)  
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Allergies

Please check all that apply to you

Dietary Restrictions

Describe your typical Meal Choices

Physical Activity

Supplement Name Strength (Milligrams) Dose (How often per Day)  
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Previous HCG use

Drop a file here or click to upload Choose File
Maximum upload size: 10MB

AGREEMENT

We are glad that you have taken this time to focus on yourself. We share in
your excitement to begin this vital step towards your weight loss goals and look forward to sharing in your journey and excitement with the results.

By typing your FULL NAME and TODAY’S DATE and then clicking on the SEND button below, you acknowledge that you have read and agree to our conditions and that the information you have provided is true and correct to the best of your knowledge.

Sending