Xenical (Orlistat) Care Request
Treatment for weight loss
Patient Name *
Patient Email Address *
Sex *
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? *
Are you breastfeeding? *
Reason for Medication (detailed is better) *
Has the patient ever had an allergic reaction to orlistat (Xenical)? *
Has the patient ever been diagnosed with cholestasis, gallstones or a problem with the gallbladder or bile duct? *
Has the patient ever been diagnosed with a malabsorption syndrome? *
I hereby request *
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.* *
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