Ibutamoren Medical Intake Form

You have purchased a prescription product. To complete your order complete the form below and we will forward your information to one of our participating providers who can treat you from the comfort of your home.

First Name*
Last Name*
Phone Number *
Email *
Address*
City *
State Of Residence*
Zip Code*
Are you allergic to any medication? *
What medications or vitamins are you taking? (List drug, dosage, and frequency) *
What is your date of birth? *
Gender* Female Male
Current Medical Problems: (Please list in space bellow) *




Health Habits & Personal Safety
Do you exercise? (Y/N)*


Are you currently dieting? (Y/N)*


Do you drink alcohol? (Y/N)*


Do you use Tobacco? (Y/N)*


Are you sexually active? (Y/N)*


What symptoms are you experiencing that you hope Ibutamoren will resolve?
Concentration difficulties*


Mood swings*


Increased sense of stress*


Decreased motivation*


Feeling depressed*


Difficulty sleeping*


Decreased energy*


Exercising less*


Decreased muscle strength*


Decreased libido/sex drive*


Feelings of fatigue or lethargy*


Decreased sociability*


Short term memory issues*


Long term memory issues*


Decreased self-confidence*


Decreased sense of well-being*


Decreased skin elasticity*


Arthritis*


Decreased sex drive*


Body aches & pains*


Decreased endurance*


Increased healing time*


Migraines or headaches*


Decreased skin tone*


Decreased muscle mass*


Tendonitis*


Skin allergy*


Headaches*


Shingles*


Susceptibility to injuries*


Osteoporosis*


Increased nipple sensitivity*


Increasing back pain*


Thinning or loss of hair*


Muscle aches & pains*


We must have a clear photo of your face and your photo ID so that we may properly identify and treat you. Your information is kept strictly private. We are a HIPAA compliant website. Take a pic right from your phone or upload a photo from your computer.
Faceshot
Photo ID
Only the medical team will see your photos

Date : 07/07/2020

Note: Your medical information will not be saved until you click on the SUBMIT button.