Personalized Wellbeing Therapy Services at VIA Co Labs Melbourne

Are you a smoker? *

Yes

No

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Do You Have A Current Medical Conditions? *

Yes

No

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Do you have High Blood Pressure? *

Yes

No

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Do you have diabetes? *

Yes

No

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Do you have a heart condition? *

Yes

No

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Do you have cancer? *

Yes

No

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Are you currently on medication? *

Yes

No

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Do you have any previous medical conditions? *

Yes

No

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Do you have a family history of significant medical conditions? *

Yes

No

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Do you have urinary or bladder pain? *

Yes

No

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Do you have frequent urination? *

Yes

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Any of the following such as loin pain, incontinence, impotence, testicular lumps or pains, penile discharge or lesions? *

Yes

No

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If a doctor has told you before that you have a special kind of sickness in your mind or feelings, can you tell us what it is? *

On a regular day, how stressed do you feel? *

If you intend to order IGF then you need to do a blood test first and send the results before you can order it. Kindly submit the blood test results: *

Submit proof of age such as upload drivers license, please. *

Have you ever used or ordered Via Co Lab’s any medicine therapy Online before? *

Was the service professional? *

Did you have an opportunity to speak with a pharmacist or doctor? *

Have you experienced any side effects? *

Have you seen positive results? *

Has your overall health improved as a result? *

Did the benefits of the Peptides Online outweigh the expenses involved? *

Would you recommend Via Co Labs to friends or family? *

First Name *

Last Name *

Date of birth *

Phone *

Address *

Email *

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I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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