Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you pregnant or breastfeeding? *

Yes

No

Do you plan to become pregnant in the next three months? *

Yes

No

Please check any of the following that do/may pertain to you: *

Anemia

Arthritis

Autoimmune Problems

Birth Defects

Kidney injury/failure

Bladder Problems

Bleeding Disorder

Blood Clots (or history of)

Cancer (or history of)

Depression

High Blood Sugar

Low Blood Sugar

Gallbladder Issues

Heart Attack

Heart Disease

Chest Pain/Angina

Hepatitis

High Blood Pressure

High Cholesterol

HIV

Kidney Disease

Liver Disease

Lung/Respiratory Disease

Mental Illness

Thyroid Problems/Nodules

Multiple Endocrine Neoplasia Type 2

Personal or Family History of Medullary Thyroid Carcinoma

Diabetic Ketoacidosis

Diabetes

Nausea/Vomiting

Constipation

GERD

Ulcers

Pancreatitis (or history of)

NONE of the Above