Mailchimp Survey

MONTHLY CHECK IN

Order your next vial, track your progress and provide us feedback.
This serves as a “check in” so we can continue to serve you. However, please know you can make an appointment to discuss further at any time!
Name
*
Current weekly dose
.25 mg.5 mg1 mg2 mg2.4 mg
Next month I would like to…
Increase my doseDecrease my doseStay the same
Which vial would you like to order? (Shipping cost included!)
*
VIAL #1 - 1 mg/mL (1 mL vial) - $290 (best for .25 mg)
VIAL #2 - 1 mg/mL (2.5 mL vial) - $340 (best for .5 mg)
VIAL #3 - 5 mg/mL (1 mL vial) - $390 (best for 1 mg)
VIAL #4 - 5 mg/mL (2.5 mL vial) - $490 (best for 2 mg AND 2.4 mg)
I'm just checking in, no order needed at this time
I’d like to discontinue
How will you pay for your order? (We must receive payment before your order can be placed.)
*
On the spas app. (RepeatMD)At the spaPlease send me a payment link (must answer following question!)
List the email address you’d like our payment link sent to.
How are you feeling overall?
Excellent!OkayHorrible!
Have you had any of the following symptoms? (check all that apply)
Nausea
Vomiting and/or diarrhea
Abdominal pain
GERD/reflux/heartburn
Height:
Weight:
Chest:
Waist:
Hips:
Right Thigh:
Right Bicep:
On average, how much water do you consume on a daily basis?
How would you rate your overall diet?
Great! Pretty good but I'll allow myself some cheats.I could do better...
Rate your exercise with 10 being “never miss a day” and 0 being “never”.
012345678910
Any questions or concerns you would like us to know about?
Prescriptions are sent to the pharmacy every Thursday. Surveys received after 9:00 am on Thursday will be sent the following Thursday.
Your order will ship directly to your home with all supplies needed. Please allow this to be up to two weeks from the Thursday submitted for your order to arrive.
Please note, payment must be submitted PRIOR to your order being placed.

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