XENICAL® MEDICAL  QUESTIONNAIRE

The following medical history will assist our staff 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. 

    Shipping Information

    First Name
    		Middle Initial
    Last Name

    Birthdate*(mm/dd/yy)
    Address*

    Apt#
    City*
    		 State *
    Zip*
    		 Country
    Phone*
    		 E-mail*
    Confirm your E-mail address*
    Sex* Height Inches
    Weight Lbs  

    *Please verify these spaces, errors may result in significant delays.

     

    Have you ever had an allergic reaction to Orlistat or any of the inactive components in Xenical?

    If yes, please list:

    Do you have any known drug allergies?

    If yes, please list in the box provided:

    Do you use tobacco products? (e.g. one pack per day x 20 years)

    If yes, please quantify type of product and usage:

    Do you consume alcohol? (e.g. 2 glasses of wine per evening)

    If yes, please quantify type of product and usage:

    Do you currently follow a routine exercise program?

      

    If yes, please quantify type and amount of exercise:

    Are you currently following a diet program?

    If yes, please explain:

    Are you currently taking Cyclosporine or any other medication used for immunosuppression?

    If yes, please list:

    Are you currently taking dietary supplements, herbal supplements and/or any type of steroids?

    If yes, please list:

    Are you currently taking any laxatives?

    If yes, please list:

    Are you currently taking any other prescription and/or over the counter medications?

    If yes, please explain: For Example: Atenolol 50mg one per day - 5 year history of hypertension (high blood pressure) well controlled with medications, Blood pressure 132/84.

    Are you planning to conceive,pregnant or breast-feeding?

    If yes, please explain:

    Is there any history of breast cancer in your family?

    If yes, please explain:

     

    Do you have any difficulty absorbing food or malabsorption symptoms?

    If yes, please explain:

     

    Do you have any complications with your gall bladder?

    If yes, please explain:

     

    Do you have any history of kidney stones?

    If yes, please explain:

     

    Do you have any complications with your thyroid?

    If yes, please explain:

     

    Are any of your parents and/or siblings overweight?

    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
    Irritable bowel syndrome Thyroid Disease
    Hypotension

    Do you have any of the medical conditions listed above?

    If yes, please explain:

    Do you have a history of any other medical conditions?

    If yes, please explain:

    Have you had any surgeries in the past five years?

    If yes, please explain:

    Have you taken Xenical previously?

    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. 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). 

      One month supply  (  90 tablets) $199 + FREE Consultation + $18 shipping    =

    $217

      Two month supply (180 tablets) $359 + FREE Consultation + $18 shipping    =

    $377

    Three month supply (270 tablets) $499 + FREE Consultation + $18 shipping     =

    $517

     

    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

     

     


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Credit card number*
 CVV2: Code 
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Expiration date*
  
Name as it appears on card

Billing Address
Billing city
Billing state
Zipcode

*Please verify these spaces, errors may result in significant delays.


Please enter special instructions.


How did you hear about us?

By submitting this consultation form:

 
  • I certify that I am 18 years of age or older.
  • I have read and agree to the Waiver of Liability.
  • I understand all the side effects of Xenical.
  • I do not have a current prescription for Xenical from another physician.
  • I certify that I am allowed by law to use the credit card I have presented.
  • I understand that falsifying information in order to obtain prescription medication is a violation of both state and federal law.  I hereby certify that I have answered all questions truthfully.
  • If outside the U.S. or Canada, I agree that I am responsible for ALL import charges, tariffs, and duties.
  • If outside the U.S. or Canada, my order is confiscated, I accept full responsibility for the loss and shall make no claim to my credit provider for non-delivery, provided always that Onlinepills.com provides proof the order was shipped.
  • I hereby certify that I have answered all questions truthfully.

Please review all information before submitting form so that your order will not be delayed.