Full Name *

Date Of Birth *

Street Address *

CountryThis product is only available in Canada!

Phone Number *

Email *

Are you pregnant or did you give birth in the past 1 month? (Yes / No) *YesNo

Have you ever had severe allergic reactions such as dyspnea, angioedema, or urticaria? (Y/N) *YesNo

Do you have any liver disorders? (Y/N) *YesNo

Do you have any kidney disorders? (Y/N) *YesNo

Do you have high blood pressure? (Y/N) *YesNo

Do you have heart disease? (Y/N) *YesNo

Do you have cancer? (Y/N) *YesNo

Do you have anı HIV infection? (Y/N) *YesNo

Do you have a seizure disorder? (Y/N) *YesNo

When was your last menstrual cycle? *YesNo

Do you have a thyroid condition? (Y/N) *YesNo

Medical HistoryMedical History

List all current medications:

Initial *

Recipient Signature *

Date