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UTM Source

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UTM Medium

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UTM Campaign

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UTM Term

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UTM Content

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UTM ID

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Placement

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Date Time

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Session Type

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Landing Page

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Referrer

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Device

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Origin Site

What is your gender?(Required)

Female

Male

Treatment Interests(Required)

Hormone Optimization Therapy

GLP-1 Semaglutide 2.4mg

NAD+

Peptides

Improve Wellness & Longevity

Improve Sexual Function

Detoxification

Better Sleep

Weight Loss

Hair Health

Boost Mental Performance

Symptoms(Required)

Lack of energy

Poor sleep

⁠Hot flushes

⁠Poor memory

Poor mental focus

⁠Low libido

Loss of muscle mass

⁠Lack of motivation

Increased skin laxity

⁠Hair loss

⁠Vaginal dryness

Decreased strength

Depression

⁠Irritability

⁠Anxiety

Date of Birth(Required)

YYYY slash MM slash DD

Height (cm)(Required)

Please enter a number greater than or equal to 0.

Weight (KG)(Required)

Please enter a number greater than or equal to 0.

How often do you exercise?(Required)

1-2 times a week

3-4 times a week

5 or more times a week

None

How long is each exercise session?(Required)

Less than 15 minutes

15 - 30 Minutes

30 - 45 Minutes

45 Minutes to an Hour

More than an hour

How is your diet on a scale of 1-10?(Required)

1 = bad and 10 = good

Please enter a number from 1 to 10.

Briefly tell us more about your diet (Optional)

Are you a professional athlete governed by a professional body?(Required)

Yes

Do you drink alcohol?(Required)

Yes

Do you smoke?(Required)

Yes

Are you pregnant?(Required)

Yes

Are you on any form of birth control/contraception?(Required)

Yes

Please provide more information(Required)

Have you previously received any hormone replacement therapy?(Required)

Yes

Please provide more information(Required)

Have you ever experienced any negative reactions (adverse effects) to hormone replacement therapy?(Required)

Yes

Please provide more information(Required)

Have you been on GLP-1 Treatment before?(Required)

Yes

Did you experience any side effects from your previous GLP-1 treatment?(Required)

Yes

Please provide more information(Required)

Within the last six months have you been under a physician’s care?(Required)

Yes

Please provide more information(Required)

Are you currently on any medication including dietary supplements, vitamins, aspirin, steroids, anticoagulant, diuretics or slimming tablets?(Required)

Yes

Please provide more information(Required)

Have you ever been admitted to hospital?(Required)

Yes

Please provide more information(Required)

Have you had previous surgical procedures?(Required)

Yes

Please provide more information(Required)

Have you ever experienced severe allergy / anaphylaxis to a product / treatment / medication?(Required)

Yes

Please provide more information(Required)

Have you suffered from heart disease / vascular aneurysms?(Required)

Yes

Please provide more information(Required)

Have you suffered from thyroid problems?(Required)

Yes

Please provide more information(Required)

Have you suffered from auto-immune disease (e.g. lupus, scleroderma, rheumatoid arthritis)?(Required)

Yes

Please provide more information(Required)

Have you suffered from asthma?(Required)

Yes

Have you suffered from epilepsy?(Required)

Yes

Have you suffered from cancer?(Required)

Yes

Please provide more information(Required)

Have you suffered from depression / psychoses / schizophrenia?(Required)

Yes

Please provide more information(Required)

Have you suffered from uncontrolled hypertension?(Required)

Yes

Please provide more information(Required)

Have you suffered from glaucoma/cataract?(Required)

Yes

Have you suffered from haemophilia or clotting abnormalities?(Required)

Yes

Please provide more information(Required)

Have you suffered from diabetes?(Required)

Yes

Have you suffered from kidney disease?(Required)

Yes

Please provide more information(Required)

Have you suffered from stomach ulcer / colitis (inflammation of the colon)?(Required)

Yes

Have you suffered from hepatitis?(Required)

Yes

Please provide more information(Required)

Have you suffered from osteoarthritis?(Required)

Yes

Have you suffered from porphyria?(Required)

Yes

Please provide more information(Required)

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Password(Required)

Enter Password Confirm Password

How did you find out about Femlab?(Required)

Referral Code

If someone you know referred you and is on hormone replacement therapy, you can use their referral code here.

Preferred contact method(Required)

This will be used for your welcoming call from us and to answer any questions you may have initially. We will always be here to assist you.

Phone(Required)

Enter the phone number you would liked to be called on. Please make sure it is correct.

Between what times are you available for a call?(Required)

Consent(Required)

1.1 That the staff of the centre perform the treatment(s) and that they are not held liable for any guarantee, warranty or assurance of the results that may be obtained
1.2 I certify that I am a competent adult of at least the age of eighteen and this is my free and voluntary decision that is executed;
1.3 I have answered all the questions contained herein with accuracy, honesty and to the best of my ability. If there are changes to my medical history, operations or medications I will be responsible for informing the centre of the updates and any other serious conditions that may be relevant;
1.4 I agree to adhere to all safety precautions and regulations during the treatments and to follow all instructions;
1.5 The centre does not take responsibility for treatments done with other practitioners or centres that may cause side effects to the therapy
1.6 My digital submission of this form indicates my informed consent to the therapy and my acceptance of the conditions outlined herein.

I herewith agree to the following:

Consent(Required)

I have read and understood the treatment information guide relating to my therapy. I have been advised that all treatments may differ due to variables such as age, lifestyle etc.

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