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Patient Medical Questionnaire

In order to safely review your order, we require information about the prescribed patient.

If you are ordering for yourself, please provide your information.

If you are ordering for a family member or pet, please answer these questions on their behalf.

Patient First and Last Name *

Gender *

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Other

Date Of Birth *

Patient Relationship *

Please indicate the patient’s height *

Please indicate the patient’s weight *

Current Medical Conditions - Please list patient's current medical condition(s) *

Drug Allergies - Please list patient's allergies and include any necessary comments *

Current Medication - Please list all medications/supplements patient currently takes *

Doctor's Information

First Name *

Last Name *

Clinic Name

Clinic Address

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Acknowledgment *

By clicking 'create account' you agree to the terms and conditions set out in the customer agreement (including schedule 'a') as found here, and you agree, on behalf of yourself, your heirs, successors, administrators and assigns, to be bound by our terms of use.

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Registration

Patient Medical Questionnaire

Doctor's Information

Pre-Mixed

Pens

Cartridges

Vials

Type 2 Diabetes (67)

Diabetes (43)

Type 1 Diabetes (38)

Kidney Disease (34)

Heart Failure (29)

High Blood Pressure (28)

Hypertension (20)

Stroke (18)

Depression (15)

Heart Attack (15)

High Blood Sugar (14)

Anxiety (13)

Cardiovascular Disease (10)

Heart Disease (10)

Angina (10)

Blood Glucose Monitoring (10)

Major Depressive Disorder (9)

Obesity (9)

Panic Disorder (9)

Atrial Fibrillation (8)

Obsessive-Compulsive Disorder (8)

Post-Traumatic Stress Disorder (8)

Hyperglycemia (8)

Bipolar Disorder (8)

Psoriatic Arthritis (8)

Asthma (8)

Blood Clots (8)

Myocardial Infarction (7)

Weight Management (7)

Deep Vein Thrombosis (7)

Pulmonary Embolism (7)

Ankylosing Spondylitis (7)

Venous Thromboembolism (6)

Diabetic Nephropathy (6)

Migraines (6)

Social Anxiety Disorder (6)

Arrhythmia (6)

Rheumatoid Arthritis (5)

Diabetic Macular Edema (5)

Neuropathic Pain (5)

Chronic Obstructive Pulmonary Disease (5)

Eye Conditions (5)

Generalized Anxiety Disorder (5)

Gestational Diabetes (5)

High Cholesterol (5)

Left Ventricular Hypertrophy (5)

Hypoglycemia (5)

Peripheral Artery Disease (4)

Registration

Patient Medical Questionnaire

Doctor's Information