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Confidential Self Evaluation & Informed Consent Form

Welcome to the HCG PROTOCOL for Weight Loss

Confidential Evaluation Form - First Part

If you are human, leave this field blank.

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.

Full Name *

Email Address *

Phone *

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