Medical Registration Form Program Patient Registration Step 1 of 3 33% Username* Password* Enter Password Confirm Password Name* First Last Email* Phone*Shipping Address* Street Address Suburb State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands How did you hear about us?*FriendFacebookGoogleOtherOther Biological Gender* Male Female Date of Birth* DD slash MM slash YYYY Occupation Current Weight (Kgs)* Current Height (CM)* Are you a Smoker?* Yes No How often do you consume alcohol?* Never 1-5 drinks per month 1-5 drinks per week More than 5 drinks per week Are you Allergic to anything?* Yes No Please list any AllergiesAre you taking any over the counter medications or supplements?* Yes No Please list any over the counter medications or supplements?Do you have or have you ever had any of the following? If so please give more detail below* None Cancer, past or present Epilepsy Hypertension Anemia Diabetes: type 1; type 2 Thyroid disorder Nausea, vomiting or diarrhea Chest pains, palpitations (irregular or fast heart beat), shortness of breath with exercise? Gluten intolerance Any Respiratory Illnesses acute and chronic Any Heart conditions, past or present History of urinary infections Current urinary symptoms like difficulty urinating, frequency of urnation Erectile dysfunction Any history of fractures, tendon tears or joint injuries Skin disorders Anxiety, depression, insomnia: other psychiatric issues Other Please provide more detail of the above*Have you ever been diagnosed with:* None Cancer Epilepsy Diabetes Type 1 Diabetes Type 2 Any heart conditions Have you ever had a stroke Other Please provide more info*Are you taking any prescribed medications?* Yes No Please list any Prescription medications you are currently taking*Name and dosage of prescribed medicationHiddenAre you currently taking any anabolics ?* Yes No Testosterone, Steroids, SARMs etcHiddenPlease specify which anabolic(s) including dosages* Do you have a family history of cancer?* Yes No Please provide info on family cancer history*Do you suffer from chest pains, palpitations (irregular or fast heart beat), shortness of breath with exercise?* Yes No Are you currently trying to conceive?* Yes No Do you suffer from any joint, muscular, connective tissue or ligament problems/injuries/conditions?* Yes No Please provide info of the above*Have you had any surgical procedures in the past 4 weeks or are planning on having any procedure done in the next 4 weeks?* Yes No Please provide info of the above*Emergency Contact First Last Emergency Contact PhoneWhat are your goals?* Weight Loss Muscle and Strength Gain Muscle and Injury Repair Anti Aging Sexual Health & Libido Memory / Cognitive Enhancement Hair Regrowth Tanning Better Sleep Immunity Have you ever been hospitalised?* Yes No What were you hospitalised for?*Have you ever been to the emergency room?* Yes No Third Choice What were you in the emergency room for?*NotesConsent* I agree to Human Enhancement Clinics terms & conditionsCAPTCHACommentsThis field is for validation purposes and should be left unchanged.
