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)

No Yes -

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 immunosuppression?

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: 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 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:

If yes, 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:

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

If you prefer to pay with a money order please mail payment to the following address:

•       1STXENICALPRESCRIPTIONS.COM
•       Box 151
•       Tyrone, Georgia 30290
  
  Please write N/A in the credit card boxes below if using a money order.

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  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 am legally allowed to receive prescription medication at my shipping address. We are currently unable to ship to residents of Michigan. 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 1stxenicalprescription.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.