What is your date of birth?

Have you taken any medicine before to lower your cholesterol?

Enter your most recent blood pressure reading from the previous six months

Are/Do you …?

Have you been diagnosed with high blood pressure or diabetes?

Do you have a family history of high cholesterol?

Do you smoke?

Smoking raises the risk of heart disease.

Yes. Smoke cigarettesYes. Use other tobacco productsNo. I quit smokingNo. I never smoked

Have you had a history of heart disease or attack peripheral artery or vascular disease?

Do you experience any of the following symptoms?

Do you have a history of hypothyroidism (low thyroid)?

Do you currently drink alcohol or alcoholic beverages?

Are you allergic to any medicines? Milk protein? Aspirin, NSAIDs, or phenylalanine?

Do you take other medication(s) or have any other medical conditions?

Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

Do you have any of these conditions?

Anything else you would like us to know?

How would you like to pay?

Billing and delivery details

Personal Details

Confirm Request and Agree to Terms