JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Xenical (Orlistat) Care Request
Treatment for weight loss
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Patient Name
*
Your answer
Patient Email Address
*
Your answer
Sex
*
Male
Female
Birth Date
*
Your answer
Phone Number
*
Your answer
Address
*
Your answer
City, State, Zip
*
Your answer
Past Medicial Problems (e.g. Asthma - if none, type "none")
*
Your answer
Current Medications (if none, type "none")
*
Your answer
Known Allergies (if none, type "none")
*
Your answer
Are you pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Reason for Medication (detailed is better)
*
Your answer
Has the patient ever had an allergic reaction to orlistat (Xenical)?
*
Yes
No
Has the patient ever been diagnosed with cholestasis, gallstones or a problem with the gallbladder or bile duct?
*
Yes
No
Has the patient ever been diagnosed with a malabsorption syndrome?
*
Yes
No
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)
*
Your answer
Credit Card (Visa/MC), exp. date, CV#
*
Your answer
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
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Infohealth.
Report Abuse
Forms
