Secure Medical Questionnaire/Order Request
The information below is needed to place your order request for medication.
We will not disclose any personal information to any outside party. See our Privacy Statement for additional information.

All fields below must be filled out for order requests.

 Customer Account Information
 
PLEASE NOTE: We will provide e-mail notifications concerning your medical consultation and order status.
First Name:  (Complete First Name - No Initials)
Last Name:
Email Address: (Like yourname@aol.com)
Date of Birth: / /
Gender:

  Payment Information
 
Payment Method:
Card Holder: (Exact Name on Credit Card Bill)
Card Number:
CVV2 Number: (Click to View CVV2 Description)
Expiration Date:


Billing Address:		  
Your billing address MUST match the address where you receive your credit card bills.
Address:
City:
State:  
Zip Code:

 Shipping/Contact Information
 
PLEASE NOTE: You will be required to sign for delivery.  You may not change the delivery address once your order is placed..
Shipping Address:  
Check This Box If Shipping Address is the Same as Billing Address
Street Address: (No P.O. Boxes)
 
City:
State: We do not ship to:
AZ, AR, CA, CO, IA, KY, LA, MO, NJ, NE, WV, and UT
  
Zip Code:
Day Time Phone: () -  Ext.
Evening Phone: () -  Ext.

 Your Medication Selection
 
Please select the product and quantity that you would like to order:
 
PLEASE NOTE: A Shipping Fee of $19.00 Will be added to your order for FEDEX shipping.
Before we ship your medication, the request must be:
1. Physician Approved
2. Processed by a licensed pharmacy
Shipping is effective as of completion of steps 1 & 2 above, not your order date.

 Medical Questionnaire
Height & Weight
Please select your height from the list and enter your current weight below:
Please select your Height:
Please enter your Weight in pounds: Lbs.
NOTE: Customers must have a body mass index of 25 or greater to request a weight loss medication.
Your Calculated Body Mass Index (BMI):
(Automated calculations, please click on box)
General Questions
Please select your answer from the drop-down list to the right of each question below:
Do you have high blood pressure?
I agree to consult my pharmacist before taking any over-the-counter medications.
Have you had a complete physical with blood tests within the last year?
I agree that I will not take this medication if I am pregnant, breast feeding, or trying to get pregnant.
Have you taken this medication before?
I agree to monitor my blood pressure by checking it at least once every 14 days. If your blood pressure is over 140/90 (meaning that if the top number is over 140 or the bottom number is over 90), you must discontinue use of medication immediately.
Do you smoke cigars or cigarettes?
How many packs of cigarettes per day do you smoke?
How long have you been smoking? years
Do you consume more than 2 servings of alcohol a day?
I agree that I cannot take this medication if I have any form of mal-absorption syndrome.
 
 
Please explain the SPECIFIC REASON for ordering this medication.  You must give a detailed
answer. The physician must know the exact nature of your medical problem or your order will be declined.
Note: This field cannot be left blank.
 
What symptoms have you been feeling / experiencing and for how long?

Note: This field cannot be left blank.
 
Please list any current medical conditions:

Note: This field cannot be left blank.
 
Please list all medications you are currently taking:
Click "None" if you are taking no other medications.

 None  I Will Specify
Do any diseases or disorders run in your family?: 
Click "None" or specify:

 None  I Will Specify
Please list all Allergies (including medications):
Click "None" if you have no Allergies.

 None  I Will Specify
Please list any Surgeries:
Click "None" if you have not had any Surgeries.

 None  I Will Specify
Is there anything else in your medical history you deem relevant?
Click "None" if you have no other relevant items to add to your medical history.

 None  I Will Specify

 Customer Agreements
 
To place an order, you must agree with the Customer Responsibility and Informed Consent Statements below. Click each link to view the documents in a pop-up window.
I Have Read, Understand and Agree with the Customer Responsibility Statement
I Have Read, Understand and Agree with the Informed Consent Agreement
I Have Read, Understand and Agree with the Notice of Privacy Practices



Click "Review/Confirm Order" to review your order request.