Our Survey | TEXAS LEAN

Our products are only available to residents of Texas, USA

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Survey

Take our survey to see if you are a candidate!

First Name

Last Name

Email

Phone

Are you pregnant or breast feeding?

Yes

No

Do you have a history of Kidney Disease?

Yes

No

Have you or anyone in your immediate family had Multiple Endocrine Neoplasm?

Yes

No

Do you have a history of Thyroid Cancer?

Yes

No

Have you ever had any gallstones or have you ever had your gallbladder removed?

Yes

No

Do you have a history of or have you ever had Cardiac Arrhythmias?

Yes

No

Do you have Diabetes?

Yes

No

What current medications are you taking?

Do you have any drug allergies?

Thank you for your survey response.

We will get back to you soon to let you know if you are a candidate.

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