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This Form Will Be Sent To Our Physician For Review And Issuing Prescriptions For Your Order

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Health and Eligibility Requirements : You hereby affirm and warrant that you are .seeking the product(s) available for purchase on this website for the purpose of weight loss and that you do not suffer from any health conditions that may contraindicate the use or effectiveness of such product(s). Specifically, you represent and warrant that you are in good health and do not have any known or undisclosed allergies that may be aggravated by the use of our product(s). Further, you confirm that you do not have, and have not been diagnosed with, any of the following conditions: Fibromyalgia Chronic Fatigue Syndrome Liver or Kidney problems Heart Problems High Blood Pressure Thyroid Issues Hormone Issues Blood Clots Pre/Peri/Post Menopause Cancer Stroke or Seizure Pancreatitis or a history of pancreatitis Medullary thyroid cancer or a history of medullary thyroid cancer Renal (kidney) impairment Type 1 diabetes or diabetic retinopathy*

Single choice
I understand and Agree

Note

if our prescriber refuse to issue script we will refund your order’s

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