Weight Loss Programs

Weight Loss Products

Medicine fulfillment provided under and by foreign medical practitioners
General Information
Full Name*

First NameLast Name
Birth Date

MonthDayYear
Shipping Address*

Street Address or Box Number

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number

Country CodeArea CodePhone Number
Gender
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.*
I acknowledge that I will remain under the care of a local healthcare professional who will continue to monitor any medications I take and any health concerns that i have.*

I acknowledge
What medications, supplements and over the counter items do you take regularly or are currently prescribed:*
Any past surgeries and hospitalizations?*
Please list any/all allergies

Health History*

Rows	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Depressive symptoms
Anxiety
Thyroid problems
Diabetes
Blood sugar irregularities
Headache
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Constipation
Diarrhea
Liver problems
Kidney problems
Irregular Heartbeat
Are you pregnant/breastfeeding
Epilepsy / Seizures
Cancer

Any additional Health History information or explanation you would like to provide?
Medicine Requested
Medicine (s) requested - check all that apply*

Metformin (Glucophage) - for weight lossRybelsus (semaglutide tablets by NovoNordisk Denmark) - for weight lossContrave (called Mysimba in UK) - for weight lossLDN (low dose naltrexone) - for weight lossSemaglutide prefilled syringes (same dosing as Wegovy) - for weight lossUSA Semaglutide compounded - $249 per month - visit NiceRx.comUSA Tirzepatide compounded - $449 per month - visit NiceRx.comOther
Quantity of Metformin 500mg sent through Insulinhub.com portal. Metformin is often taken starting at 500mg daily and increasing up to 1000mg twice daily.*

Metformin 500mg x 300 tablets @ $59Metformin 500mg x 600 tablets @ $99nothing at this time
Quantity of Rybelsus sent through Insulinhub.com portal.*

Rybelsus 3mg x 30 tablets @ $249Rybelsus 3mg x 60 tablets @ $449Rybelsus 3mg x 90 tablets @ $599Rybelsus 7mg x 30 tablets @ $249Rybelsus 7mg x 60 tablets @ $449Rybelsus 7mg x 90 tablets @ $599Rybelsus 14mg x 30 tablets @ $249Rybelsus 14mg x 60 tablets @ $449Rybelsus 14mg x 90 tablets @ $599nothing at this time
Quantity of Mysimba (naltrexone/bupropion) sent through Insulinhub.com portal.*

Mysimba 8/90mg x 112 tablets @ $225Mysimba 8/90mg x 224 tablets @ $425Mysimba 8/90mg x 336 tablets @ $625Mysimba 8/90mg x 448 tablets @ $799nothing at this time
Quantities of Low Dose Naltrexone requested to be sent through InsulinHub.com portal*

Naltrexone 1.5mg x 100 @ $89Naltrexone 1.5mg x 200 @ $155Naltrexone 1.5mg x 300 @ $210Naltrexone 1.5mg x 400 @ $265Naltrexone 1.5mg x 500 @ $320Naltrexone 1.5mg x 100 @ $89nothing at this time
Quantities of Semaglutide PFS requested to be sent through InsulinHub.com portal*

Semaglutide 0.25mg x 4 (first month) x @ $175Semaglutide 0.5mg x 4 (second month) x @ $175Semaglutide 0.1mg x 4 (third month) x @ $175Semaglutide 1.75mg x 4 (fourth month) x @ $175Semaglutide 2.4mg x 4 (maint dose) x @ $199Semglutide 3 month plan - $499 (any dose - shipped monthly)Semglutide 6 month plan - $899 (any dose - shipped monthly)nothing at this time
Describe fully the name, strength, and directions of use for the "other" medicine requested*
I understand that these medicines are manufactured in India (unless otherwise specified) and will be shipped directly from India. I also accept that shipping times will take an average 3 weeks once payment is received.*

I acknowledge
I understand that InsulinHub.com is given full permission to this form immediately and will confirm my order. I understand that my order may be cancelled for any reason prior to acceping payment.*

I acknowledge
I hereby confirm that all questions were answered accurately and I hold harmless all pharmacy and medical providers. I have approached this medical provider myself as if personally in his office in the country of his practice, requesting a specific medication for the purpose given. I will not take the medicine itself unless I am advised by a local physician directly. I also hold harmless the pharmacy and website platform by which I found this medicine and am completing this order. I take full personal responsibility for my decision to consult with a foreign medical service and to receive this medicine from that same jurisdiction.*

I acknowledge
My preference for payment (Visa/MC)

I will call InsulinHub at 1-718-312-8727I will visit InsulinHub on their secure LiveChat at https://direct.lc.chat/12078399/I prefer for InsulinHub to contact me directlyInsulinHub already has my billing information
How did you hear about us?
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Weight Loss Products

General Information

Medical History

Medicine Requested