New Patient Form

THIS FORM IS FOR PATIENTS WHO HAVE PURCHASED A HOMEKIT.

Please purchase a HOMEKIT before filling out this form. After filling out this medical history form a chart can be created for you. This chart will be given to the Physician. The Physician will contact you within 24-48 hours.

  • Feet and Inches (Example: 5' 1")
  • Please fill out as completely as possible.
    Check ALL that apply

  • Risk of Proposed Treatment

    I understand that I will be having a video consult with WildBerryMD before the Natural HCG or Fatburner/B12 injections are shipped to me. I have had full opportunity to ask any questions, after reading this form, and those were answered. I understand that if I develop side effects from my natural HCG drops or Fatburner/B12 injections, I will discontinue use and notify WildBerryMD staff immediately and in the event the problem is severe leading to medical emergency, I will go to the nearest emergency room for evaluation and management.

  • Risks Associated with Being Overweight or Obese

    I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease, and to arthritis of the joints, hips, knees, and feet.I understand these risks may be modest if I am not very much overweight but that these risks can go up significantly the more overweight I am.

  • No Guarantee

  • MM slash DD slash YYYY