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Current Patient Reorder Questionnaire
Step
1
of
6
16%
Name
First
Last
Email
Phone
Consent
I agree to the privacy policy.
Date of Birth
MM slash DD slash YYYY
Sex
Male
Female
Current Weight
(Required)
Healthy Weight Goal
Height
(Required)
4'6" (137.16 cm) or <
4'7" (139.7 cm)
4'8" (142.24 cm)
4'9" (144.78 cm)
4'10" (147.32 cm)
4'11" (149.86 cm)
5'0" (152.4 cm)
5'1" (154.94 cm)
5'2" (157.48 cm)
5'3" (160.02 cm)
5'4" (162.56 cm)
5'5" (165.1 cm)
5'6" (167.64 cm)
5'7" (170.18 cm)
5'8" (172.72 cm)
5'9" (175.26 cm)
5'10" (177.8 cm)
5'11" (180.34 cm)
6'0" (182.88 cm)
6'1" (185.42 cm)
6'2" (187.96 cm)
6'3" (190.5 cm)
6'4" (193.04 cm)
6'5" (195.58 cm)
6'6" (198.12 cm)
6'7" (200.66 cm)
6'8" (203.2 cm)
6'9" (205.74 cm)
6'10" (208.28 cm)
6'11" (210.82 cm)
7'0" (213.36 cm) or >
Have you been taking your dose consistently?
Yes
Mostly Yes
Sometimes
No
Are you experiencing any side effects? If yes, please describe.
(Required)
Any changes in your health since your previous order?
Is this reorder for a vitamin injection?
Yes
No
Vitamin injection only: dose preference
The prescriber will determine the right dose for you, however, please indicate a preference.
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