XENICAL® MEDICAL  QUESTIONNAIRE The following medical history will assist our physicians in deciding whether Xenical® is appropriate for your condition. All information provided will remain secure, confidential and subject to all patient/physician privilege laws. Please take a few minutes to fill in the following information as thoroughly and accurately as possible. Please note there will be a $75.00 consultation fee if the physician determines that Xenical® is appropriate for your condition. Remember that the consultation fee includes six (6) additional refills over the next twelve (12) months. There will be No consultation fee if the physician determines that Xenical® is not appropriate for your condition.

Please fill in all fields. Failure to do so will delay your order processing. All fields must be complete to submit form. If field does not pertain to you please type N/A (Not Applicable).

First Name Middle Initial Last Name Birthdate (mm/dd/yy) Address Apt. # City State Zip Country Phone Email Confirm Your Email   Sex Male Female -   Weight     Lbs Kg - Height     Inches Centimeters

Have you ever had an allergic reaction to Orlistat or any of the inactive components in Xenical®? Yes No - If yes, please list:

Do you have any known drug allergies? Yes No - If yes, please list in the box provided:

Do you use tobacco products?  (e.g. one pack per day x 20 years) Yes No - If yes, please quantify type of product and usage:

Do you consume alcohol?  (e.g. 2 glasses of wine per evening) Yes No - If yes, please quantify type of product and usage:

Do you currently follow a routine exercise program? Yes No - If yes, please quantify type and amount of exercise:

Are you currently following a diet program? Yes No - If yes, please explain:

Are you currently taking Cyclosporine or any other medication used for immunosuppresion? Yes No - If yes, please list:

Are you currently taking any steroids? Yes No - If yes, please list:

Are you currently taking any laxatives? Yes No - If yes, please list:

Are you currently taking any other prescription and/or over the counter medications? Yes No - If yes, please explain:  (e.g. Atenolol 50mg one per day - 5 year history hypertension (high blood pressure) well controlled with medication, Blood pressure 132/84)

Are you pregnant or breast-feeding? Yes No - If yes, please explain:

Is there any history of breast cancer in your family? Yes No - If yes, please explain:

Anorexia   Idiopathic Steatorrhea   Bulemia   Inflammatory Bowel Disease   Cholestasis   Crohn's Disease   Cholelithiasis (gallstones)   Ulcerative Colitis   Diabetes   Liver Disease   Peptic ulcer (duodenal or gastric ulcer)   Pancreatitis   Esophogitis   Malabsorption Syndrome   Gastritis   Celiac Sprue   Hypercholesterolemia   Tropical Sprue   Hypertension   Whipple's Disease   Hypotension   Thyroid Disease

If you have answered yes to any of the above please explain:

Do you have a history of any other medical conditions? Yes No - If yes, please explain:

Have you had any surgeries in the past five years? Yes No - If yes, please explain:

You have completed the medical questionnaire XENICAL® ORDER FORM Please take a few minutes to fill in the following information as thoroughly and as accurately as possible. There will be NO charges if your Xenical® prescription is not approved. Please fill in all spaces completely. Spaces left blank will only delay your order. If a question does not apply to you please write in Not Applicable (NA). A signature is required for delivery; therefore, we are unable to ship to a P.O. Box. Your approved Xenical® prescription entitles you to your original order plus (4) additional refills at this time or over the next twelve (12) months. Please check a box below to indicate your order. You may also order refills at this time by selecting the quantity that you desire.

One month supply (90 tablets) $140 + $75 consultation + $18 shipping  = $233   Two month supply (180 tablets) $280 + $75 consultation + $18 shipping  = $373   Three month supply (270 tablets) $420 + $75 consultation + $18 shipping = $513

International orders are $46 to ship. If you choose to ship your order outside the U.S., you are assuming all liability for any customs, duties or tariffs. If for some unforeseen reason your order is seized by Customs, we are unable to refund your money. By selecting International shipping, you are agreeing with these terms. Note: International orders please add an additional $28.00 to the above totals difference between ($46.00 - $18.00). SECURE ORDERING PROCESS Visa Mastercard American Express

Credit Card Number    Expiration Date    Billing Address Name (as it appears on credit card) Billing City Billing State Billing Zip Code Billing Country

Please enter special instructions:

How did you hear about us?

By submitting this consultation form:

Next, simply click on the following "Submit" button and we will promptly process your Xenical order: