Spa Me Now - Medical History & Contact Information

Spa Me Now - Medical History & Contact Information
Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Driver's License #*
Driver License State of Issue*
Address
Street Address*
City*
State*
Zip Code*
Medical Information
Emergency Contact Full Name*
Physician Full Name*
Physician Phone Number*
Height*
Feet (') and Inches(")
Weight*
in lbs
Please list any drug allergies you have*
Please list any medications you currently take*
Have you had any previous surgeries or procedures?*
Have you had any problems sleeping?*
Have you experienced any decrease in sex drive or libido?*
Do you have any chronic medical conditions?*

YesNo
Additional information about your chronic medical condition.
How many hours a week do you exercise?
Do you have a history of hypoglycemia?*

YesNo
Do you have any history of thyroid cancer in your family?*

YesNo
Have you ever had pancreatitis?*

YesNo
Do you have any renal/kidney issues?*

YesNo
The following questions are for those ordering Semaglutide or Tirzepatide.
Do any of the following apply to you? Semaglutide is safe and effective with many pre-existing conditions, with the exception of the following:

Currently pregnant or plan to become pregnant in the next year?Currently breastfeeding?Currently being treated for cancer?Active or history of eating disorder?Active gallbladder disease?Active substance abuse or dependency?Type 1 diabetes?Bariatric surgery? (within the past 18 months)Pancreatitis within the past 6 months or history of pancreatitis caused be taking GLP-1?History of medullary thyroid cancer/MEN syndrome of family, history of either of these?
Please read and confirm you understand the Statement of Patient:
By purchasing products from Spa Me Now, you understand that results are not guaranteed, and individual outcomes may vary. You assume full responsibility for any risks, including potential side effects or interactions with other medications. Spa Me Now, is not liable for any adverse reactions or health issues that may arise from the use of these products. Please read about the possible side effects of both tirzepatide and semaglutide prior to purchasing.

We strongly recommend that you see your primary care physician (PCP) regularly and inform them of any medications or treatments you are receiving from Spa Me Now. It is important to be monitored by your PCP to ensure the safe and effective use of these products. If you experience any issues, please contact us directly.

All sales are final, and no refunds or returns will be accepted. By completing your purchase, you confirm your agreement to these terms and conditions.
Please confirm*

I have read and understand the above statement
Email*
example@example.com
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Spa Me Now - Medical History & Contact Information

Personal Information

Address

Medical Information

The following questions are for those ordering Semaglutide or Tirzepatide.

Please read and confirm you understand the Statement of Patient: