Patient Health Information Form - NewBeginnings Medical

Skip to content

(877) 424-9994
Cart

Search for:

Weight Loss
Health & Wellness
Vitality
About Us
- Our Team
- Testimonials
Contact Us

Weight Loss
Health & Wellness
Vitality
About Us
- Our Team
- Testimonials
Contact Us

Patient Health Information Formadmin2021-02-11T18:14:58+00:00

Black Friday Form Destop

PATIENT MEDICAL HISTORY FORM
Full Name*
How Did You Hear About Us
Gender*
Height*
State Issued ID*
Driver's License Number*
Weight*
BMI [If Known]
Date of Birth*
MM slash DD slash YYYY
Blood Pressure*
Pulse*
Describe Your General Health*
List any Prescription, Supplements & Over the Counter Medications you are CURRENTLY TAKING*
- None
- List
List of Prescription
List any of your Allergies [Include Foods, Drug &, Other Allergies]*
Have you used a discount coupon for this order?*
- Yes
- No
Name of the person who referred you*
Email of the person who referred you*
Comments:
I have answered the above general information questions honestly and completely to the best of my knowledge.*
- Check Indicates Approval
PATIENT MEDICAL HISTORY FORM
Have You ever been Diagnosed or Treated For the Following
- Alcohol/Drug Addiction
- Gall Bladder Disease
- Menstrual Disorder
- Angina [Unstable]
- Gout*
- Neurologic Disorder/Migraines
- Asthma
- Heart Arrhythmias/Stroke*
- Polycystic Ovarian Syndrome*
- Autoimmune Disorder
- High Blood Pressure
- Pregnant / Nursing [NOW]*
- Breathing Disorder /Breath Shortness
- Heavy Periods
- Psychiatric Disorder/Anxiety
- Bulimia/Anorexia
- High Cholesterol/Triglycerides
- Pulmonary*
- Gastrointestinal Disorder
- HIV/AIDS
- Recent Weight Change
- Chronic Constipation
- Irritable Bowel Syndrome
- Serious Chronic/Acute Illness*
- Crohn's Disease/Colitis*
- Kidney Disease / Stones*
- Sleep Problems
- Deep Vein Thrombosis*
- Liver/Disease
- Diabetes*
- Thyroid Disease*
- Lung/Breathing Problems
- Insulin Dependent
- Have You Had Cancer?*
What Type of Cancer:
When Was Your Cancer Last Treated?
What Results Were Found During Your Last Treatment?
* Specific Medical Conditions
I have answered the above medical information questions honestly and completely to the best of my knowledge and I also will complete the Medical Consent and Agreement to Acquire HCG Products form attached.*
- Check Indicates Approval

Black Friday Form Mobile

PATIENT MEDICAL HISTORY FORM
FULL NAME*
How Did You Hear About Us
Reason For HCG Treatment*
Gender*
Height*
State Issued ID*
Driver's License Number*
Weight*
Desired Weight*
Your Highest Weight*
BMI [If Known]
Date of Birth*
MM slash DD slash YYYY
Blood Pressure*
Pulse*
Describe Your General Health*
List any Prescription, Supplements & Over the Counter Medications you are CURRENTLY TAKING*
- None
- List
List any Prescription
List any of your Allergies [Include Foods, Drug &, Other Allergies]*
Have you used a discount coupon for this order?*
- Yes
- No
Name of the person who referred you*
Email of the person who referred you*
Comments:
I have answered the above general information questions honestly and completely to the best of my knowledge.*
- Check Indicates Approval
PATIENT MEDICAL HISTORY FORM
Have You ever been Diagnosed or Treated For the Following
- Alcohol/Drug Addiction
- Gall Bladder Disease
- Menstrual Disorder
- Angina [Unstable]
- Gout*
- Neurologic Disorder/Migraines
- Asthma
- Heart Arrhythmias/Stroke*
- Polycystic Ovarian Syndrome*
- Autoimmune Disorder
- High Blood Pressure
- Pregnant / Nursing [NOW]*
- Breathing Disorder /Breath Shortness
- Heavy Periods
- Psychiatric Disorder/Anxiety
- Bulimia/Anorexia
- High Cholesterol/Triglycerides
- Pulmonary*
- Gastrointestinal Disorder
- HIV/AIDS
- Recent Weight Change
- Chronic Constipation
- Irritable Bowel Syndrome
- Serious Chronic/Acute Illness*
- Crohn's Disease/Colitis*
- Kidney Disease / Stones*
- Sleep Problems
- Deep Vein Thrombosis*
- Liver/Disease
- Diabetes*
- Thyroid Disease*
- Lung/Breathing Problems
- Insulin Dependent
- Have You Had Cancer?*
What Type of Cancer
When Was Your Cancer Last Treated?
What Results Were Found During Your Last Treatment?
* Specific Medical Conditions
I have answered the above medical information questions honestly and completely to the best of my knowledge and I also will complete the Medical Consent and Agreement to Acquire HCG Products form attached.*
- Check Indicates Approval

Title

Security

Hosting Server

Website Software

Prescribing Pharmacy

Consultation Platform

Legal

TERMS & CONDITIONS

HIPAA NOTICE OF PRIVACY PRACTICES

Contact Info

124 Lakeshore Dr Unit 631, North Palm Beach, FL 33408

(877) 424-9994

support@newbeginningsmedical.com

Have A Question?

Full Name*
Email Address*
Phone Number
Question
Email
This field is for validation purposes and should be left unchanged.

Copyright 2025 newbeginningsmedical.com | All Rights Reserved | Website Design by SiteDesignZ Web Design and Local SEO

New Beginnings Medical, LLC and TeleHCG, LLC
will not be accepting any orders after July 5, 2025.

We want to thank you for your loyal patronage over the past 18 years.

If you are inquiring about an out-standing order, previously placed please call:
[877] 424-9994

WE’LL LET YOU KNOW!

If your State is not listed, please feel free to leave your contact information and we will notify you immediately when it becomes available in your area.

Full Name

Email Address

Phone Number

Your State

CAPTCHA

Notify Me