Health History

01

About you

First name*

Enter your first name.

Last name*

Enter your last name.

Phone*

Enter a 10 digit phone number.

Email*

Enter a valid email.

Street address*

Enter your street address.

City*

Required.

State*

Required.

ZIP*

5 digits.

Date of birth*

Enter your date of birth. You must be 18 or older.

Sex assigned at birth*

MaleFemale

Select one.

Your goals* Pick all that apply

Pick at least one.

02

Current height*

Select feet and inches.

Current weight (lbs)*

Enter your weight in pounds.

Do you take any medications or supplements?*

YesNo

Select one.

Do you have any allergies?*

YesNo

Select one.

Do any of these apply to you?*

Personal or family history of MEN2 or medullary thyroid cancer

YesNo

History of pancreatitis

YesNo

Diabetic retinopathy

YesNo

Currently taking medication to lower blood sugar

YesNo

Neuromuscular conditions

YesNo

Answer each question.

Have you been diagnosed with any of the following?* Pick all that apply

Pick at least one, or None of the above.

03

Labs

Have you had bloodwork in the last 6 months?*

YesNo

Select one.

04

Consent and signature

Tap each section to review before you sign.

Billing terms

Subscription billing. Monthly plans renew every month on the same date. 3 month prepaid plans renew every 3 months. Your plan continues until you cancel.

Cancel anytime. Cancel by emailing [email protected] at least 7 days before your next renewal date.

Payment. Axiom does not accept or bill insurance. Treatment is self-pay. HSA and FSA cards are accepted. There is no membership fee.

Medical review and refunds

Medical review. An Axiom Medical Professional reviews your health history before your order ships. Some treatments also require a telehealth visit.

Refunds. If an Axiom Medical Professional determines a treatment is not appropriate for you, your order is refunded in full. Medications cannot be returned once they have shipped.

Consent to treatment and telehealth

I consent to evaluation and care by an Axiom Medical Professional, including by telehealth. Treatment is provided only when an Axiom Medical Professional determines it is clinically appropriate, and a treatment may be changed or declined based on my health history and labs.

I confirm the information in this form is true and complete, and I will tell my Axiom Medical Professional about any change in my health, medications or pregnancy status. Results vary and no outcome is guaranteed. Axiom services do not replace my primary care provider or emergency care. In an emergency I will call 911.

Dispute resolution

Any dispute related to Axiom services or billing will be resolved by binding individual arbitration under the rules of the American Arbitration Association, rather than in court, except that either party may bring an individual claim in small claims court. Claims may be brought only on an individual basis and not as part of any class or representative action. This agreement is governed by the laws of the Commonwealth of Pennsylvania.

Required. I have read and accept the terms of service, telehealth consent and HIPAA notice, including the terms above.You must accept to continue. Text me order, shipping and appointment updates from Axiom Healthspan. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not a condition of purchase. Text me offers and news from Axiom Healthspan, which may be sent using automated technology. Message frequency varies. Message and data rates may apply. Reply STOP to opt out. Consent is not a condition of purchase.

Signature* Sign with your finger or mouse

Sign above

Please sign.

Your information is encrypted and reviewed only by the Axiom care team. These statements have not been evaluated by the FDA. Axiom products are not intended to diagnose, treat, cure or prevent any disease.

One last step. Your health history.

About you

Health history

Labs

Consent and signature

You are all set.