Xenical (Orlistat) Care Request

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Treatment for weight loss

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Patient Name *

Patient Email Address *

Sex *

Male

Female

Birth Date *

Phone Number *

Address *

City, State, Zip *

Past Medicial Problems (e.g. Asthma - if none, type "none") *

Current Medications (if none, type "none") *

Known Allergies (if none, type "none") *

Are you pregnant? *

Yes

Are you breastfeeding? *

Yes

Reason for Medication (detailed is better) *

Has the patient ever had an allergic reaction to orlistat (Xenical)? *

Yes

Has the patient ever been diagnosed with cholestasis, gallstones or a problem with the gallbladder or bile duct? *

Yes

Has the patient ever been diagnosed with a malabsorption syndrome? *

Yes

I hereby request *

Orlistat 120 mg x 84 caps @ $120 (-10% discount) + $20 doctor fee = $125 USD

Orlistat 120 mg x 168 caps @ $230 (-10% discount) + $20 doctor fee = $225 USD

Orlistat 120 mg x 252 caps @ $310 (-10% discount) + $20 doctor fee = $299 USD

Nothing at this time

Name (as appears on the credit card) *

Credit Card (Visa/MC), exp. date, CV# *

I hereby confirm that all questions were answered accurately and I hold harmless all medical providers approving or not approving a prescription. I have approached the medical provider myself requesting a specific medication for the purpose listed.al setting. I understand that this medicine will be shipped from a licensed pharmacy in the United Kingdom and shipping times are usually 7 to 10 days however shipping delays are acceptable and common with the COVID 19 outbreak.* *

I agree

I disagree

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