🩺 Before You Order: Complete this Quick Medical Consultation

To ensure your safety and best results, please complete the following medical intake form before your order is processed.

All responses are confidential, securely stored, and reviewed by a licensed healthcare provider prior to shipment. This helps us determine your eligibility.

Your completion of this form constitutes a request for telehealth review and delivery of wellness support under the supervision of a licensed medical provider.

IMPORTANT: You must complete this short Medical Consulation before placing order. Your order will not be approved or shipped without.

💖 Let’s Get to Know You!

Welcome, beautiful! Before we personalize your Pink Skinny journey, we’d love to get to know you a little better.

This quick form helps our team understand your goals, preferences, and any health considerations so we can make sure you’re getting the safest, most effective, and most supportive experience possible.

There are no wrong answers — just honest ones! Your information stays 100% confidential and helps us deliver care that’s as unique as you.

Let’s glow ✨

First Name *

Last Name *

Phone *

Email *

Date of birth *

How did you hear about Pink Skinny? *

A Friend

Facebook

Instagram

Google

If a friend referred you, tell us who so we can send them a Thank You Gift! *

By completing this Consent, you concent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to 936-284-3964 for assistance. You can reply STOP to unsubscribe at any time.

Everyone’s journey is unique ... what brings you to Pink Skinny today?

Choose what applies to you!

Support healthy, sustainable weight loss

Boost energy and fight fatigue

Burn stubborn body fat

Improve skin clarity and glow

Balance hormones and feel like myself again

All of the above

🌿 How Would You Describe Your Current Health Wellness?

What do you feel most days?

I feel okay, but I know I could feel better

I’ve noticed unwanted weight gain or bloating I can’t get rid of

I feel tired, sluggish, or low energy most days

I’m already on a wellness journey and looking for a boost

I feel amazing and want to maintain my results!

💧 Let’s Talk Lifestyle

These quick questions help us get a clearer picture of your day-to-day health habits:

Are you staying hydrated? How many glasses of water are you drinking per day?

Do you workout? How often?

Do you take vitamins or supplements?

Yes

Sometimes - when I remember

If so, what vitamins and/or supplements are you currently taking?

🩺 Health History & Safety

We’re all about personalized, responsible wellness. Please answer honestly — everything is confidential and helps us ensure your safety 💖

Details of above conditions or any other condition not listed *

Do you have any known allergies?

Yes

Seasonal

If yes, please list allergies

________________________

Do you have any know allergies to any of the following:

Informed Consent & Agreement

________________________

I acknowledge that there are inherent risks associated with ‘at home’ injection kits, which include, but are not limited to: *

Discomfort, bruising and pain during injection

Inflammation of vein used for injection, phlebitis

Severe allergic reaction

I understand the above potential side effects

________________________

Confirm *

I understand that other unforeseen risks, other than those listed, may arise, and I agree that I will seek medical attention at my own expense if necessary. I understand that it is my responsibility to disclose any health condition or medication that might affect the treatment. I acknowledge that individual results can vary, and I may need multiple treatment sessions for the desired results.

I confirm that the information provided above is true and accurate. By signing below, I give consent to purchase vitamin wellness kits from Pink Skinny, I understand all sales are final, and I accept the risks and responsibilities of use.

I confirm that all information provided is true and complete to the best of my knowledge. I understand that this is a wellness-based support protocol and not a prescription treatment. I consent to the review of my health information by a licensed medical provider, and I agree to the Terms of Use, Refund Policy, and Medical Disclaimer provided by Pink Skinny.

🖊️ Medical Consent & Authorization

By signing below, I confirm that:

I have truthfully completed this health questionnaire to the best of my ability.
I understand the information provided is for wellness and educational purposes only and is not intended to diagnose, treat, cure, or prevent any disease.
I authorize Pink Skinny and its licensed partners or providers to evaluate my responses and determine if I am a candidate for vitamin injections or related services.
I accept full responsibility for the use of any products I purchase, and I acknowledge that I have been informed of all potential risks and benefits.
I understand that once shipped, all sales are final and non-refundable, and I am responsible for tracking, receiving, and properly storing all products.
I agree that Pink Skinny is not liable for lost or stolen packages and that delivery concerns must be addressed directly with the carrier (USPS or UPS).
I agree to hold harmless Pink Skinny and its affiliates from any claims, demands, or liabilities arising from my use of these products or services.

Date Today: *

Full Name

Please Sign Here: *

Clear

💖 Thank You!

Thank you so much for completing your Pink Skinny Wellness Survey!

Your answers help us personalize your journey and ensure your experience is safe, effective, and tailored just for you.

✨ You're officially one step closer to your glow-up - make sure to click SUBMIT below!

If approved, you’ll be redirected to complete your purchase.
Orders ship same-day or next-business-day.

If we have any questions, a member of our team will reach out within 24 hours.

We’re so excited to support your transformation. Let’s do this, Glow Babe! 💪💉💕