Shipping Information

First Name	Middle Initial
Last Name	Birthdate*(mm/dd/yy)
Address*	Apt#
City*	State / Province SELECT ONE OUTSIDE THE US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba Newfoundland New Brunswick Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon
Zip*	Country   Albania Algeria American Samoa Andorra Angola Anguilla Antigua Argentina Armenia Aruba Austria Australia Azerbaijan Bahamas Bahrain Bangladesh Barbados Barbuda Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Botswana British Virgin Is. Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Chad Channel Islands Chile China Colombia Congo Congo, The Republic of Cook Island Costa Rica Croatia Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia, Republic of Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Ireland, Northern Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Korea, South Kuwait Kyrgyzstan Laos Latvia Lebannon Lesoth Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives, Rep of Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nepal Netherlands Netherland Antilles New Caledonia New Zealand Nicaragua Panama Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saba Saipan Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia South Africa Spain Sri Lanka St. Barthelemy St. Eustatius St Kitts/Nevis St Lucia St. Martin St Vincent Suriname Swaziland Sweden Switzerland Syria Tanzania Taiwan Thailand Togo Trinidad and Tobago Tunisia Turkey Turkmenistan Republic of Turks & Caicos Uganda Ukraine Uruguay United Arab Emirates United Kingdom United States U.S. Virgin Islands Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Yemen Zambia Zimbabwe SELECT ONE
Phone*	E-mail*
Confirm your E-mail address*
Sex* male female -	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?

YES NO Choose

If yes, please list:

Do you have any known drug allergies?

Yes No Choose

If yes, please list in the box provided:

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

YES NO Choose

If yes, please quantify type of product and usage:

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

No Yes Choose

If yes, please quantify type of product and usage:

Do you currently follow a routine exercise program?

Yes No Choose   

If yes, please quantify type and amount of exercise:

Are you currently following a diet program?

YES NO Choose

If yes, please explain:

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

YES NO Choose

If yes, please list:

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

YES NO Choose

If yes, please list:

Are you currently taking any laxatives?

YES NO Choose

If yes, please list:

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

YES NO Choose

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?

YES NO Choose

If yes, please explain:

Is there any history of breast cancer in your family?

YES NO Choose

If yes, please explain:

 

Do you have any difficulty absorbing food or malabsorption symptoms?

YES NO Choose

If yes, please explain:

 

Do you have any complications with your gall bladder?

YES NO Choose

If yes, please explain:

 

Do you have any history of kidney stones?

YES NO Choose

If yes, please explain:

 

Do you have any complications with your thyroid?

YES NO Choose

If yes, please explain:

 

Are any of your parents and/or siblings overweight?

YES NO Choose

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?
YES NO Choose

If yes, please explain:

Do you have a history of any other medical conditions?

YES NO Choose

If yes, please explain:

Have you had any surgeries in the past five years?

YES NO Choose

If yes, please explain:

Have you taken Xenical previously?

YES NO Choose

If yes, please explain:

 

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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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 www.lifestylemeds.net 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.