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Consultation/Waiver
 


This form will generate a document that you can print out, complete your credit card details by hand and fax or post to Online-Xenical.

You can also use this form to post your order to Online-Xenical and make payment using a cashiers check or money order.

If you have a prescription written by your regular doctor, please include the original copy of the prescription, when you post your order to us.

Medical Questionnaire Offline

First Name:
Last Name:
Address:
City:
State/Provence:
Zip:
Country of Residence:
Phone:
Fax:
Email:

 
Date of Birth:
 

Use mm/dd/yy format ie, 03/21/70
Sex:        Female Male
Height:
Weight:

 
Known Allergies:
 
Current Medications:
Please list all prescription and non-prescription ("over the counter") medications you are currently taking, even if only occasionally.
Do you have any medical conditions, particularly diabetes, or high cholesterol levels? If so please give details. If you are unsure, you should ask your regular doctor.
Do you consider anything else in your medical history to be relevant?
Please give details
Repeat orders - enter the 6 digit number from label on Xenical box. If you already have a prescription from your regular doctor, enter 123456.

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If this is a repeat consultation have you experienced any allergic reaction to or side effects from XENICAL? If so please give details.
Billing and Shipping Information
 
Supply of Xenical
4 weeks (84 capsules) US$99.00*
8 weeks (168 capsules) US$198.00*
12 weeks (252 capsules) US$297.00*
A delivery charge of US$15 will also apply.
Delivery Address:
(if different than previous)
City:
(if different than previous)
State/Provence:
(if different than previous)
Zip:
(if different than previous)
Country of Residence:
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Delivery Instructions:
(if any)
 

 
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