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

You can also use this form to post your order to About-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:

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Country of Residence:

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Date of Birth:

Use mm/dd/yy format ie, 03/21/70

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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.

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.

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