First Name
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Last Name
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Phone
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The number you use with us
Please provide an update on how you are feeling on the medication:
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Goals you want to still achieve:
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Weight Loss
Energy
Recovery
Sexual Performance/Health
Cognitive Function (memory, focus, etc.)
Muscle Growth
Overall Health
Date of last in person doctor appointment
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Medical Condition Updates
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Anemia
Asthma
Blood Clotting Disorder
Cancer
Diabetes
Heart Attack/Failure/Disease
Hepatits A
Hepatitis B or C
High Blood Pressure
High Cholesterol
Kidney Problems
Liver Disease
Low Blood Pressure
Stroke
Thyroid Disease
Other
None
Medical Conditions Continued if You Selected Other:
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Street Address
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